mp-139
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Sensory Stimulation for Coma Patients

Policy Number: MP-139

Latest Review Date: December 2020

Category: Therapy

Policy Grade: Active policy but no longer scheduled for regular literature reviews and update.

POLICY:

Sensory stimulation for coma patients is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Sensory stimulation programs are intended to promote positive changes in consciousness levels as noted in awakening and enhancing the rehabilitative potential of coma patients. Most programs include stimulation involving auditory, visual, olfactory, gustatory, tactile and physical stimulation. Various stimuli may be used for each sense. Protocols may differ with respect to who performs the stimulation and where. Professionals include nurses, occupational therapists, physical therapists, and speech-language therapists. In some cases, family members may be trained in the techniques and are given primary responsibility for providing the therapy. Treatment may be performed in the hospital, the patient’s home or a nursing home.

KEY POINTS:

The most recent literature search was performed through December 2020.

Summary of Evidence:

Studies include Cochrane systematic reviews of sensory stimulation of patients in coma, vegetative state and following a traumatic brain injury. Studies were reviewed and revealed the overall methodology was poor and the studies differed in design and conduct.  None of the studies reviewed provided useful and valid results on the outcomes of clinical relevance for these patients. Studies concluded that there was no reliable evidence to support the effectiveness of multisensory stimulation programs in patients in coma or vegetative states. Given the lack of rigorous, clinically meaningful studies for inclusion and the qualitative methodological approach that was used in analysis, more research is needed to confirm the effectiveness of this treatment modality.

PRACTICE GUIDELINES AND POSITION STATEMENTS:

American Academy of Neurology

Disorders of Consciousness (DoC) Practice Recommendations

Recommendations Concerning the Adult Population

Recommendation 9: Patients with DoC lasting at least 28 days may have a prolonged recovery over months to years, and many will remain severely disabled. Employment and personal finances in both the short-term and the long-term will be significantly impacted, and these effects will have implications for family members. Patients and families benefit from planning in advance for an expected prolonged recovery.

  • Level A In patients with a prolonged DoC, once a prognosis has been established that indicates a likelihood of severe long-term disability, clinicians must counsel family members to seek assistance in establishing goals of care and completing state-specific forms regarding medical decision making (e.g., medical orders for life-sustaining treatment [MOLST] forms) if not already available, applying for disability benefits, and starting estate, caregiver, and long-term care planning.

U.S. Preventive Services Task Force

Not applicable.

KEY WORDS:

Sensory stimulation, coma stimulation, vegetative state, traumatic brain injury, coma stimulation sessions, coma arousal therapy, multisensory stimulation programs, coma care

APPROVED BY GOVERNING BODIES:

Not applicable

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING:

CPT:

97139

Unlisted therapeutic procedure (specify)

97799

Unlisted physical medicine/rehabilitation serviced or procedure

 

HCPCS:

S9056

Coma stimulation; per diem

REFERENCES:

  1. American Academy of Neurology. Practice Guideline Update: Disorders of Consciousness. Neurology. 2018. https://www.aan.com/Guidelines/home/GetGuidelineContent/929
  2. American Academy of Neurology. Practice Parameters: Assessment and Management of Patients in the Persistent Vegetative State (Summary Statement). Report of the quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1994; 45(5):1015-1018. Available at https://www.aan.com/Guidelines/home/GetGuidelineContent/83.
  3. Blue Cross and Blue Shield Association.  Medical Policy Reference Manual.  Sensory stimulation for coma patients, June 2009.
  4. Bos S.  Coma stimulation.  Online J Knowl Synth Nurs, February 1997; 4:1.
  5. Davis AE and Gimenez A.  Cognitive-behavioral recovery in comatose patients following auditory sensory stimulation.  J Neurosci Nurs, August 2003; 35(4): 202-9, 214.
  6. Karma D and Rawat AK.  Effect of stimulation in coma.  Indian Pediatrics, October 2006, Vol. 43, pp. 856-860.
  7. Li J. et al. Sensory stimulation to improve arousal in comatose patients after traumatic brain injury: a systematic review of the literature. Neurol Sci 2020 Sep;41(9):2367-2376. doi: 10.1007/s10072-020-04410-9. Epub 2020 Apr 22.
  8. Lippert-Gruner M, Wedekind C and Klug N.  Outcome of prolonged coma following severe traumatic brain injury.  Brain Inj, January 2003; 17(1): 49-54.
  9. Lombardi F, Taricco M, De Tanti A, et al.  Sensory stimulation of brain-injured individuals in coma or vegetative state:  Results of a Cochrane systematic review.  Clin Rehabil, August 2002; 16(5): 464-72.
  10. Megha M, Harpreet S, Nayeem Z. Effect of frequency of multimodal coma stimulation on the consciousness levels of traumatic brain injury comatose patients. Brain Inj. 2013; 27(5):570-577.
  11. Meyer MJ, Megyesi J, Meythaler J, et al. Acute management of acquired brain injury Part III: an evidence-based review of interventions used to promote arousal from coma. Brain Inj. 2010; b24(5):722-729.
  12. National Institute of Neurological Disorders and Stroke.  Traumatic brain injury:  Hope through research, http://www.ninds.nih.gov/health_and_medical/pubs/tbi.htm.
  13. Oh H and Seo W.  Sensory stimulation programme to improve recovery in comatose patients.  J Clin Nurs, May 2003; 12(3): 394-404.
  14. Pierce JP, Lyle DM, Quine S, et al.  The effectiveness of coma arousal intervention.  Brain Inj, Apr-Jun 1990; 4(2): 191-7.
  15. Padilla R, Domina A. Effectiveness of sensory stimulation to improve arousal and alertness of people in a coma or persistent vegetative state after traumatic brain injury: A systematic review. Am J Occup Ther. 2016; 70(3):1-8.
  16. Salmani, Mohammadi, Rezvani, Kazemnezhad. The effects of family-centered affective stimulation on brain-injured comatose patients' level of consciousness: A randomized controlled trial. Int J Nurs Stud. 2017; 74:44-52.

POLICY HISTORY:

Medical Policy Group, September 2003 (1)

Medical Policy Administration Committee, September 2003

Available for comment November 3-December 17, 2003

Medical Policy Group, September 2005 (1)

Medical Policy Group, September 2007 (1)

Medical Policy Group, September 2009 (1)

Medical Policy Group, March 2012: Effective March 12, 2012 Policy no longer scheduled for regular literature reviews and updates.

Medical Policy Group, August 2019 (3): 2019 Updates to Key Points. A peer reviewed literature analysis was completed and no new information was identified that would alter the coverage statement of this policy.

Medical Policy Group, December 2020 (6): Updates to Key Points, Key Words (traumatic brain injury, coma stimulation sessions, coma arousal therapy, multisensory stimulation programs, coma care), USPSTF, Practice Guidelines and References. No change in policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.