Latest Review Date: March 2024

Category: Therapy                                                                  

POLICY:

Hippotherapy is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Hippotherapy, also referred to as equine-assisted therapy movement therapy, describes a treatment strategy that uses equine movement to engage sensory, neuromotor, and cognitive systems to achieve functional outcomes. Hippotherapy has been proposed as a type of therapy for individuals with impaired walking or balance.

Hippotherapy

Hippotherapy has been proposed as a technique to decrease the energy requirements and improve walking in individuals with cerebral palsy. It is thought that the natural swaying motion of the horse induces a pelvic movement in the rider that simulates human ambulation. In addition, variations in the horse’s movements can prompt natural equilibrium movements in the rider. Hippotherapy is also being evaluated in individuals with multiple sclerosis and other causes of gait disorders, such as strokes.

As a therapeutic intervention, hippotherapy is typically conducted by a physical or occupational therapist and is aimed at improving impaired body function. Therapeutic horseback riding is typically conducted by riding instructors and is more frequently intended as social therapy. It is hoped that the multisensory environment may be beneficial to children with profound social and communication deficits, such as autism spectrum disorder and schizophrenia. When considered together, hippotherapy and therapeutic riding are described as equine-assisted activities and therapies.

This policy addresses equine-assisted activities that focus on improving physical functions such as balance and gait.

KEY POINTS:

The most recent literature update was performed through January 31, 2024.

Summary of Evidence

For individuals who have cerebral palsy, multiple sclerosis, stroke, or gait and balance disorders other than cerebral palsy, multiple sclerosis, and stroke who receive hippotherapy, the evidence includes systematic reviews, randomized trials, and case series. Relevant outcomes include symptoms and functional outcomes. Studies in cerebral palsy, multiple sclerosis, stroke, and other indications have had variable findings. The randomized trials are generally small and have significant methodologic problems. In the largest randomized trial conducted to date (92 children), which had blinded outcome assessment, hippotherapy had no clinically significant impact on children with cerebral palsy. There are no RCT s showing that hippotherapy is superior to alternative treatments for patients with multiple sclerosis. Hippotherapy for other indications has been compared primarily with no intervention and, although some benefits have been seen, it has not been shown to be more effective than other active therapies. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Academy of Neurology

In 2014, the American Academy of Neurology authored a guideline on complementary and alternative medicine for multiple sclerosis. The guideline stated that there was insufficient evidence to support or refute the effectiveness of hippotherapy.

American Hippotherapy Association, Inc.

In their 2021 statement of best practices, the AHA states that hippotherapy is contraindicated during acute exacerbations of multiple sclerosis and other conditions that can flare.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Equine Movement Therapy, Hippotherapy, therapeutic horseback riding, simulated hippotherapy

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:

There is no specific CPT code for this procedure.

HCPCS:

REFERENCES:

1. Abdel-Aziem AA, Abdelraouf OR, Ghally SA, et al. A 10-Week Program of Combined Hippotherapy and Scroth's Exercises Improves Balance and Postural Asymmetries in Adolescence Idiopathic Scoliosis: A Randomized Controlled Study. Children (Basel). Dec 30 2021; 9(1).
2. American Academy of Neurology. Complementary and Alternative Medicine in Multiple Sclerosis. March 2014.www.aan.com/Guidelines/home/GuidelineDetail/641.
3. American Hippotherapy Association, Inc. Statements of best practice for the use of hippotherapy by occupational therapy, physical therapy, and speech-language pathology professionals. Revised February 2021. www.americanhippotherapyassociation.org/assets/docs/AHA%20Statements%20of%20Best%20Practice%20February%202021.pdf.
4. Araujo TB, Silva NA, Costa JN et al. Effect of equine-assisted therapy on the postural balance of the elderly. Rev Bras Fisioter 2011; 15(5):414-419.
5. Bronson C, Brewerton K, Ong J et al. Does hippotherapy improve balance in persons with multiple sclerosis: a systematic review. Eur J Phys Rehabil Med Sep 2010; 46(3):347-53.
6. Bunketorp-Käll L, Pekna M, Pekny M, et al. Effects of horse-riding therapy and rhythm and music-based therapy on functional mobility in late phase after stroke. NeuroRehabilitation. Dec 18 2019; 45(4): 483-492.
7. Bunketorp Kall L, Lundgren-Nilsson A, Blomstrand C, et al. The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial. BMC Neurol. Nov 11 2012; 12:141.
8. Chinniah H, Natarajan M, Ramanathan R, et al. Effects of horse riding simulator on sitting motor function in children with spasticcerebral palsy. Physiother Res Int. Oct 2020; 25(4): e1870.
9. Çoban O, Mutluay F. The effects of mechanical hippotherapy riding on postural control, balance, and quality of life (QoL) in patients with stroke. Disabil Rehabil. Jun 11 2023: 1-10.
10. Davis E, Davies B, Wolfe R, et al. A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy. Dev Med Child Neurol Feb 2009; 51(2):111-9.
11. De Araujo TB, de Oliveria RJ, Martins WR et al. Effects of hippotherapy on mobility, strength and balance in elderly. Arch Gerontol Geriatr 2013; 56(3):478-481.
12. Frevel D, Maurer M. Internet-based home training is capable to improve balance in multiple sclerosis: a randomized controlled trial. Eur J Phys Rehabil Med. Feb 2015; 51(1):23-30.
13. Giagazoglou P, Arabatzi F, Dipla K et al. Effect of a hippotherapy intervention program on static balance and strength in adolescents with intellectual disabilities. Res Dev Disabil 2012; 33(6):2265-70.
14. Heussen N, Häusler M. Equine-Assisted Therapies for Children With Cerebral Palsy: A Meta-analysis. Pediatrics. Jul 01 2022; 150(1).
15. Homnick DN, Henning KM, Swain CV et al. Effect of therapeutic horseback riding on balance in community-dwelling older adults with balance deficits. J Altern Complement Med Jul 2013; 19(7); 622-626.
16. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
17. Kaya Y, Saka S, Tuncer D. Effect of hippotherapy on balance, functional mobility, and functional independence in children with Down syndrome: randomized controlled trial. Eur J Pediatr. Jul 2023; 182(7): 3147-3155.
18. Kim SG, Lee CW. The effects of hippotherapy on elderly persons' static balance and gait. J Phys Ther Sci. Jan 2014; 26(1):25-27.
19. Kwon JY, Chang HJ, Yi SH, et al. Effect of hippotherapy on gross motor function in children with cerebral palsy: a randomized controlled trial. J Altern Complement Med. Jan 2015; 21(1):15-21.
20. Lavín-Pérez AM, Collado-Mateo D, Caña-Pino A, et al. Benefits of Equine-Assisted Therapies in People with Multiple Sclerosis: A Systematic Review. Evid Based Complement Alternat Med. 2022;2022: 9656503.
21. Lechner HE, Kakebeeke TH, Hegemann D, et al. The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury. Arch Phys Med Rehabil Oct 2007; 88(10):1241-1248.
22. Lee CW, Kim SG, Yong MS. Effects of hippotherapy on recovery of gait and balance ability in patients with stroke. J Phys Ther Sci. Feb 2014; 26(2):309-311.
23. McGibbon NH, Benda W, Duncan BR et al. Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy. Arch Phys Med Rehabil 2009; 90(60):966-74.
24. Munoz-Lasa S, Ferriero G, Valero R et al. Effect of therapeutic horseback riding on balance and gait of people with multiple sclerosis. G Ital Med Lav Ergon 2011; 33(4):462-467.
25. Qin Z, Guo Z, Wang J. Multiple Equine Therapies for the Treatment of Gross Motor Function in Children with Cerebral Palsy: A Systematic Review. J Community Health Nurs. Jan 16 2024: 1-14.
26. Selph SS, Skelly AC, Wasson N, et al. Physical Activity and the Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury. Number 241. Agency for Healthcare Research and Quality, US Department of Health and Human Services; 2021. www.ncbi.nlm.nih.gov/books/NBK574875/#ch4.s5
27. Silkwood-Sherer D and Warmbier H. Effects of hippotherapy on postural stability, in persons with multiple sclerosis: A pilot study. J Neurol Phys Ther Jun 2007; 31(2):77-84.
28. Silkwood-Sherer DJ, Killian CB, Long TM et al. Hippotherapy-an intervention to habilitate balance deficits in children with movement disorders: a clinical trial. Phys Ther May 2012; 92(5): 707-717.
29. Tseng SH, Chen HC, Tam KW. Systematic review and meta-analysis of the effect of equine assisted activities and therapies on gross motor outcome in children with cerebral palsy. Disabil Rehabil. Jan 2013; 35(2):89-99. 
30. Wood WH, Fields BE. Hippotherapy: a systematic mapping review of peer-reviewed research, 1980 to 2018. Disabil Rehabil. May 2021; 43(10): 1463-1487
31. Zadnikar M, Kastrin A. Effects of hippotherapy and therapeutic horseback riding on postural control or balance in children with cerebral palsy: a meta-analysis. Dev Med Child Neurol Aug 2011; 53(8):684-91.

POLICY HISTORY:

Medical Policy Group, April 2010 (3)

Medical Policy Administration Committee May 2010

Available for comment May 7-June 21, 2010

Medical Policy Group, March 2011 (1)

Medical Policy Group, December 2011(3): Updated Key Points & References

Medical Policy Group, November 2012(3): 2012 Update to Description, Key Points & References

Medical Policy Panel, November 2013

Medical Policy Group, January 2014 (2): policy updated with literature search through September 2013. No change in policy statement. Description, Key Points, References updated.

Medical Policy Panel, November 2014

Medical Policy Group, November 2014 (3): Updates to Key Points and References. No change in policy statement.

Medical Policy Panel, March 2016

Medical Policy Group, March 2016 (6): Updates to Description, Key Points, Key Words and References; no change to policy statement.

Medical Policy Panel, March 2017

Medical Policy Group, March 2017 (6): Updates to Description, Key Points: no change to policy statement.

Medical Policy Panel, March 2018

Medical Policy Group, March 2018 (6): Updates to Description and Key Points.

Medical Policy Panel, March 2019

Medical Policy Group, April 2019 (3): 2019 Updates to Key Points and References. No changes to policy statement or intent.

Medical Policy Panel, March 2020

Medical Policy Group, March 2020 (3): 2020 Updates to Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Panel, March 2021

Medical Policy Group, April 2021 (3): 2021 Updates to Key Points, and References. Policy statement updated to remove “not medically necessary.” No other changes to policy statement or intent.

Medical Policy Panel, March 2022

Medical Policy Group, March 2022 (3): 2022 Updates to Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Panel, March 2023

Medical Policy Group, March 2023 (3): 2023 Updates to Key Points, Benefit Application, and References; no change to Policy Statement.

Medical Policy Panel, March 2024

Medical Policy Group, March 2024 (11): Updates to Key Points, Benefit Application, and References; no change to Policy Statement.

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.