Latest Review Date: June 2024

Category: Therapy                                                                

POLICY:

Constraint-induced movement therapy for the treatment of motor disorders such as those caused by stroke, traumatic brain injury, or cerebral palsy is considered investigational.

Constraint-induced language therapy for the treatment of aphasia is considered investigational.

For sensory and/or auditory integration therapy, please refer to medical policy #333- Sensory Integration Therapy and Auditory Integration Therapy.

For cognitive/neurobehavioral/neurorestorative rehabilitation, please refer to medical policy #600- Cognitive Neurobehavioral/Neurorestorative Rehabilitation.

DESCRIPTION OF PROCEDURE OR SERVICE:

Constraint-induced movement therapy (CIMT), also known as constraint-induced therapy (CIT) or forced use movement therapy, is a therapeutic approach to rehabilitation of movement after stroke or other neurologic events.  CIMT has been used to improve motor function in patients following CVA.  The intensity and schedule of delivery of CIMT is different from that of traditional physical therapy.  CIMT involves a technique of restraining the unimpaired limb and forcing the use of the impaired limb during normal daily activities and rehabilitation exercises.  The non-paretic upper extremity is secured in a sling for 90% of waking hours, while the paretic arm receives intensive training in a variety of tasks six hours per day for two to three weeks.  Pediatric CIT may also be referred to as ACQUIREc Therapy.

CIMT has been used in patients with chronic and subacute CVA, chronic traumatic brain injury, incomplete spinal cord injury, cerebral palsy, fractured hip, phantom limb pain, as well as musicians with focal hand dystonia.  The exact mechanism by which CIMT produces its therapeutic effect is not known, but imaging studies suggest that use-dependent cortical reorganization may occur after CI therapy.

Recently, constraint-induced language therapy (CILT) or constraint-induced aphasia therapy (CIAT) has been used to treat patients with aphasia.  CILT differs from usual aphasia treatment approaches in that no compensatory nonverbal communications (e.g., gesture, drawing, and writing) are allowed during the language activities.  Improved verbal responses are the goal of treatment.  Proponents of this therapy hypothesize that by limiting the patient’s use of compensatory communications or even giving up on the message altogether during the therapy session, the brain is forced to adapt and find an alternate way to express the idea, i.e., verbalization and spoken words.  Treatment is intense and frequent lasting six hours per day for five days per week. 

KEY POINTS:

Literature review completed through June 2024.

Summary of Evidence

There continues to be little evidence to evaluate the efficacy of CIMT for motor disorders. Among three small controlled trials published to date, there were trends supporting a treatment effect. Because the methods and outcomes used varied considerably among these trials, it is unclear which techniques, if any, are clinically useful.

A literature search identified one randomized controlled trials for using CILT to treat aphasia. The authors of this trial could not rule out that the possibility that conventional therapy performed in a massed-practice fashion also could result in pronounced behavioral improvement within a few days. In addition, small case series reporting on a limited number of participants with short follow-up were noted. There is little evidence to evaluate the efficacy of CILT for aphasia.

Finally, there is no documented standardized protocol for performing CIMT.  Future studies are needed to determine the best protocol for sustained results.

KEY WORDS:

Constraint-induced movement therapy (CIMT), forced use movement therapy, constraint-induced therapy, CIT, constraint-induced language therapy, CILT, constraint-induced aphasia therapy, CIAT, ACQUIREc Therapy

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: Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING: 

CPT codes:               

These services should be billed as a global fee at the end of therapy under the unlisted code.

These procedures have also been identified as being billed on the following:

REFERENCES:

1. Abdullahi A, Truijen S, Umar NA, et al. Effects of lower limb constraint induced movement therapy in people with stroke: A systematic review and meta-analysis. Front Neurol. 2021 Mar 23;12:638904.
2. Bonifer N, Anderson KM.  Application of constraint-induced movement therapy for an individual with severe chronic upper extremity hemiplegia. Physical Therapy, April 2003; 83(4): 384-398.
3. Boyd RN, Morris ME, Graham HK Management of upper limb dysfunction in children with cerebral palsy: A systematic review. European Journal of Neurology, November 2001; 8 Suppl 5: 150-166.
4. Brown J. Constraint induced therapy for aphasia.  Advance for Speech Language Pathologists and Audiologists 2004; 14(40):14. 
5. Chiu HC, Ada L. Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: A systematic review. J Physiother. 2016 Jul;62(3):130-137.
6. Dromerick A, AW, Edwards DF, Hahn M Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke? Stroke, December 2000; 31(12): 2984-2988.
7. Fleet, A., Page, S., et al. Modified Constraint-Induced Movement Therapy for Upper Extremity Recovery Post Stroke: What Is the Evidence? Top Stroke Rehabil 2014 Jul-Aug; 21(4):319–331.
8. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press
9. Kunkel A, et al. Constraint-induced movement therapy for motor recovery in chronic stroke patients. Archives Physical Medicine Rehabilitation, June 1999; 80(6): 624-628.
10. Liepert J, et al. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000 Jun; 31: 1210-1216.
11. Mark VW, Taub E, Uswatte G, et al.  Constraint-induced movement therapy for the lower extremities in multiple sclerosis: case series with 4-year follow-up. ACRM 2013;94:75-60.
12. Miller, G. Management and prognosis of cerebral palsy. UpToDate, Post TW (Ed), Waltham, MA. 
13. Martínez-Costa Montero MC, Cabeza AS. Effectiveness of constraint-induced movement therapy in upper extremity rehabilitation in patients with cerebral palsy: A systematic review. Rehabilitacion (Madr). 2021 Jul-Sep;55(3):199-217.
14. Miltner WH, et al.  Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: A replication. Stroke, March 1999; 30(3): 586-592.
15. Page SJ, et al.  Modified constraint induced therapy: A randomized feasibility and efficacy study. Journal of Rehabilitation Research & Development, Sept/Oct 2001, Vol. 38, No. 5: 583-90.
16. Page SJ, et al.  Modified constraint-induced therapy after subacute stroke: A preliminary study. Neurorehabilitation and Neural Repair, September 2002; 16(3): 290-295.
17. Pulvermüller F, Neininger B, Elbert T, et al.  Constraint-induced therapy of chronic aphasia after stroke.  Stroke 2001; Jul 32(7):1621-26. 
18. Raymer AM, Roitsch J. Effectiveness of Constraint-Induced Language Therapy for Aphasia: Evidence From Systematic Reviews and Meta-Analyses. Am J Speech Lang Pathol. 2023 Oct 17;32(5S):2393-2401.
19. Raymer A. Constraint-induced language therapy.  A systematic review.  The ASHA Leader 2009.  www.asha.org/Publications/leader/2009/090210/090210e.htm. 
20. Schaechter JD, et al.  Motor recovery and cortical reorganization after constraint-induced movement therapy in stroke patients: A preliminary study. Neurorehabilitation and Neural Repair, December 2002; 16(4): 326-338.
21. Sterling C, Taub E, Davis D et al. Structural neuroplastic change after constraint-induced movement therapy in children with cerebral palsy. Pediatrics 2013 May;131(5);e1664-9.
22. Taub E, et al.  Constraint-induced movement therapy:  A new family of technique with broad application to physical rehabilitation—A clinical review. Journal of Rehabilitation Research and Development, July 1999, Vol. 36, No. 3, pp. 237-251.
23. Taub E, et al. Constraint-induced movement therapy to enhance recovery after stroke. Current Atherosclerosis Report, July 2001; 3(4): 279-286.
24. Taub E, et al.  Efficacy of constraint-induced motor therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics, 2004 Feb;113(2):305-12.
25. Taub E. New treatments in neurorehabilitation founded on basic research. Nature Reviews/Neuroscience, 2002 Mar;3(3):228-36.
26. Taub E, et al.  Technique to improve chronic motor deficit after stroke. Archives Physical Medicine Rehabilitation, 1993 Apr;74(4):347-54.
27. van der Lee JH.  Constraint-induced therapy for stroke:  More of the same or something completely different? Current Opinions in Neurology, December 2001; 14(6): 741-744.
28. van der Lee JH.  Forced use of the upper extremity in chronic stroke patients: Results from a single blind randomized clinical trial.  Stroke, November 1999; 30(11): 2369-2375.
29. Winstein CJ, et al.  Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. Neurorehabilitation and Neural Repair, September 2003; 17(3): 137-152.
30. Wolf SL, Winstein CJ, Miller JP, et al.  Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke.  The EXCITE randomized clinical trial.  JAMA, November 2006, Vol. 296, No. 17, pp. 2095-2104.
31. Wolf SL, Winstein CJ, et al.  Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomized trial.  Lancet Neurol 2008; 7: 33-40.
32. www.strokeassociation.org. Constraint-induced language therapy for aphasia. 2010.  
33. Yoon, JA, Koo B, Shin MJ, et al.  Effect of Constraint-Induced Movement Therapy and Mirror Therapy for Patients with Subacute Stroke.  Annals of Rehabilitation Medicine 2014; Aug 38(4):458-466.

POLICY HISTORY:

Medical Policy Group, July 2003

Medical Policy Group, July 2004 (2)

Medical Policy Administration Committee, August 2004

Available for comment August 11-September 24, 2004

Medical Policy Group, July 2006 (1)

Medical Policy Group, July 2008 (1)

Medical Policy Group, July 2010 (1): Reviewed, no updates

Medical Policy Group, December 2011 (2), Description, Policy, Key Words, Key Points, Coding, and References updated

Medical Policy Administration Committee, January 2012

Available for comment January 11 - February 27, 2012

Medical Policy Group, December 2012 (3): 2013 Coding Updates: Verbiage change to Code 97530 (removed “by the provider”)

Medical Policy Group, April 2014 (2): No change in policy statement.  Two references added.

Medical Policy Group, June 2015 (6): Updates to Key Points and References; no change in policy statement 

Medical Policy Group, October 2015 (4): Added “refer to” statements under Policy section for MP #333 and 600.

Medical Policy Group, December 2016: 2017 Annual Coding Update. Created Previous Coding section and moved deleted cpt codes 97001-97004 to this section.  Added new cpt codes 97161 – 97168 to current coding.

Medical Policy Group, September 2018 (3): Updates to Key Points and References. No changes to policy statement or intent.

Medical Policy Group, October 2019 (3): 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, June 2021 (3): Updates to Key Points. Policy statement updated to remove “not medically necessary,” no change to policy statement or intent. 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, June 2022 (3): Updates to Key Points and References. Reviewed by consensus. 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, June 2023 (11): Updates to Key Points, Benefit Application and References. Reviewed by consensus. 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, June 2024 (11): Updates to Key Points and References. Reviewed by consensus. A peer-reviewed literature analysis was completed and no new information was identified that would alter the coverage statement of this policy.

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.