Hippotherapy and Recreational Therapy Corporate Medical Policy

Hippotherapy and Recreational Therapy Corporate Medical Policy File name: Hippotherapy File code: UM.REHAB.08 Origination: 07/2011 Last Review: 03/2015 Next Review: 03/2015 Effective Date: 06/01/2015 Description Hippotherapy, also referred to as equine movement therapy, describes physical therapy using a horse. Hippotherapy has been proposed as a type of physical therapy for patients with impaired walking or balance. Policy When a service is considered investigational Literature on hippotherapy is limited, primarily consisting of uncontrolled case series and small controlled trials from outside the United States. In the largest randomized trial conducted to date (72 children), hippotherapy was found to have no clinically significant impact on children with cerebral palsy. Two small trials from departments of hippotherapy and rehabilitation science in Asia have compared hippotherapy with treadmill training in older adults and in post-stroke patients. These trials show some advantage over treadmill training. Independent replication and comparison with other established treatments for stroke rehabilitation are needed. Hippotherapy for other indications has been compared primarily with no intervention and has not been shown to be more effective than other active therapies. Therefore, the treatment is considered investigational. When a service is considered not medically necessary Recreational activity as physical therapy is considered not medically necessary, as it does not meet all of the criteria for physical therapy services as outlined in the Policy Guidelines, and is not generally recognized as an appropriate therapeutic intervention by the American Physical Therapy Association. (See BCBSVT policy on Physical Therapy). Coding Information Click the links below for attachments, coding tables & instructions. Attachment I- CPT & HCPCS Coding Table Page 1 of 9

Health Care Procedure Coding System (HCPCS) codes related to chemotherapy drugs, drugs administered other than oral method, and enteral/parenteral formulas may be subject to National Drug Code (NDC) processing and pricing. The use of NDC on medical claims helps facilitate more accurate payment and better management of drug costs based on what was dispensed and may be required for payment. For more information on BCBSVT requirements for billing of NDC please refer to the provider portal http://www.bcbsvt.com/provider-home latest news and communications. Policy Background Patients with spastic cerebral palsy frequently have impaired walking ability due to hyperactive tendon reflexes, muscle hypertonias, and increased resistance to increasing velocity of muscle stretch. These abnormalities result in a lack of selective muscle control and poor equilibrium responses. Hippotherapy has been proposed as a technique to decrease the energy requirements and improve walking in patients 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 also prompt natural equilibrium movements in the rider. Hippotherapy is also being evaluated in patients with multiple sclerosis and developmental disorders such as Down syndrome. Hippotherapy is a therapeutic intervention that 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 equineassisted activities and therapies. This policy addresses equine-assisted activities that focus on improving physical functions such as balance and gait. Simulated hippotherapy using a new device has been studied in European centers. Therapeutic interventions using such a device would be conducted in physical and occupational therapy settings and are outside the scope of this policy. Regulatory status Not applicable. Rationale This policy was created in 1999 and has been updated periodically using the MEDLINE database. The most recent literature review was conducted through September 22, 2014. Following is a summary of key studies to date. Cerebral Palsy A number of systematic reviews on hippotherapy in children with cerebral palsy have been published. One of the systematic reviews concluded that there was evidence from 1 or more randomized controlled trials (RCTs) of fair quality that a short intervention of hippotherapy is effective for treating muscle symmetry in the trunk and hip when compared with static sitting. The review found 3 quasi- Page 2 of 9

experimental studies with positive results for gross motor function and functional performance in the home and community. Another systematic review reported that 5 of 6 moderate quality studies (small sample sizes and lack of a control nonriding group) found improved gross motor function in children with cerebral palsy. A systematic review from 2009 found strong evidence that children and adolescents with developmental disabilities derive health benefits from participation in group exercise programs, treadmill training, or therapeutic riding/hippotherapy; however, 3 of the studies included in the review showed that therapeutic horseback riding is no more effective than other therapies for improving muscle tone in children with cerebral palsy and that it is no more effective than no intervention for posture, self-esteem, and global behavior. In 2011, Zadnikar and Kastrin published a meta-analysis of hippotherapy and therapeutic horseback riding in children with cerebral palsy.4 Included were 8 studies that met the inclusion criteria of a quantitative study design and outcomes that included postural control or balance. There was no minimum number of subjects (one of the studies described 2 children) and the median quality score was 10.5 out of a maximum of 16 (range, 5-13). The meta-analysis included 84 children with cerebral palsy in the intervention groups and 89 children in the comparison groups (39 with cerebral palsy, 50 nondisabled). The treatment effect on postural control or balance, which was coded as a dichotomous outcome (positive effect or no effect), showed a positive effect in 76 of the 84 children (90%) in the intervention group. In the comparison group, 21 of the 39 children (54%) with cerebral palsy felt positive effects from the comparison treatment, which consisted of continuation of their weekly physical therapy and/or occupational therapy, or sitting on a barrel or in an artificial saddle. Although this difference was statistically significant, the clinical significance of the effect cannot be determined from this analysis. In addition, the analysis found heterogeneity among the studies, which typically would preclude meta-analysis, and a funnel plot showed asymmetry, indicating a possible publication bias. This meta-analysis is also limited by the inclusion of poor quality studies. A 2012 meta-analysis included 5 studies on therapeutic horseback riding and 9 studies on hippotherapy with a total of 277 children with cerebral palsy. Both RCTs and observational studies were included that evaluated pre-riding compared with post-riding results; 10 of the 14 studies provided level 4 evidence. Methodologic limitations of the studies included use of non-validated outcome measures and lack of clinically meaningful differences between groups. Meta-analysis indicated that 8 to 10 minutes of hippotherapy reduced asymmetrical activity and improved postural control, but long-term hippotherapy or therapeutic riding (8-22 hours) did not have a statistically significant effect on Gross Motor Function Measure (GMFM) in children with spastic cerebral palsy. A limitation of this meta-analysis is the inclusion of observational studies (pre-post comparisons) without a control group. In 2009, a randomized trial was published that included 72 children (85% of the 99 families enrolled) aged 4 to 12 years with cerebral palsy who completed a 10-week session of hippotherapy with pre- and post-treatment assessments. Randomization to hippotherapy or a waiting-list control with usual therapy was stratified by age and level of gross motor function. The physical therapist assessor was blinded to the randomization, and the participants were asked not to mention if they had completed the intervention at the time of the assessment. No differences between the hippotherapy and control groups were found for functional status (therapist-assessed) or child-reported quality of life. Minor differences were found in parent-reported quality of life and child health scores in the domain of family cohesion. Overall, Page 3 of 9

hippotherapy was not found to have a clinically significant impact on children with cerebral palsy. McGibbon et al investigated the impact of hippotherapy on symmetry of adductor muscle during walking. In phase 1 of the trial, they randomly assigned 47 children aged 4 to 16 years with spastic cerebral palsy to receive a single 10-minute session of either hippotherapy or barrel sitting. Adductor muscle symmetry was measured before and after the session. The hippotherapy group demonstrated a statistically significant difference in adductor symmetry after this single intervention. Six of the children went on to participate in a phase 2, 36-week study (12 weeks without hippotherapy [baseline], 12 weeks of weekly intervention, 12 weeks without intervention). Four of 6 subjects showed improved symmetry during walking after 12 weeks of intervention, and improvement was maintained after 12 more weeks. All 6 children improved on the GMFM-66, and 1 child began walking without a walker after 4 weeks of hippotherapy. Five children improved in at least 1 area of Self-Perception Profiles. The authors note a number of limitations of the study including small sample size in phase 2, the diversity of subjects in the distribution of their spasticity, and the inclusion of children with mixed characteristics. Other examples of the primary literature include a study by Sterba et al, who reported on the outcomes of horseback riding in 17 subjects with cerebral palsy. Gross motor function measurements were assessed before and after a once weekly horseback-riding program for 18 weeks. Gross motor function total scores improved by 7.6% after 18 weeks, returning to baseline 6 weeks after the program ended. In another study, Benda et al used surface electromyography to assess outcomes in 15 children with cerebral palsy who were randomly assigned to either horseback riding or to sitting stationary astride a barrel. The authors reported that the hippotherapy group showed greater symmetry of muscle activity. The clinical significance of this outcome is uncertain. A series of 11 children aged 5 to 13 years with cerebral palsy demonstrated improved trunk/head stability and upper-extremity reaching/targeting after 12 weekly 45-minute sessions of hippotherapy. Results were compared with those of 8 children without disability who did not receive an intervention. The impact of hippotherapy versus other forms of therapy directed to trunk/head stability and upper extremity reaching cannot be determined from this study. Multiple Sclerosis Hippotherapy for patients with multiple sclerosis was addressed in a 2010 systematic review of 3 studies. Included in the review is a case control study by Silkwood-Sherer and Warmbier that found that 14 weekly sessions of hippotherapy improved balance in 9 subjects with multiple sclerosis (MS) in comparison with a control group of 6 patients. Each of the other studies, both case series, included 11 subjects. The review concluded that the studies provided emerging, but limited, evidence that hippotherapy improves balance in persons with MS while acknowledging limitations of small sample size, lack of randomization, especially given the variable nature of MS, and lack of controls in 2 studies. Another non-rct compared therapeutic horseback riding (with nontherapist riding instructors) versus traditional physical therapy in 27 patients with MS. The therapeutic horseback riding focused on progressively challenging the rider s motor skills while the individualized physical therapy consisted of aerobic, balance, strengthening, and flexibility exercise sessions. The interventions were selfselected and were provided in 20 sessions over 6 months. The therapeutic horseback-riding group showed a significant improvement in the balance subscale of Page 4 of 9

the Performance-Oriented Mobility Assessment and 2 gait parameters (stride time and ground reaction forces). Five of 12 horseback riders (42%) showed a clinically significant improvement. Gait speed and cadence and the Extended Disability Status Scale and the Barthel Index were not significantly improved. No significant change was found in the control group. It was not reported if the changes found after therapeutic horseback riding were significantly greater than those of the physical therapy control group. Balance Deficits in Older Adults In 2014, Kim and Lee reported a randomized trial comparing hippotherapy versus treadmill in 30 community-dwelling older adults.14 Training was conducted for 20 minutes, 3 times per week, for 8 weeks. Eight participants withdrew during the course of the study. After 8 weeks of exercises, step lengths increased and step time decreased significantly in both groups (significance was determined at p<0.05). Sway on a balance task also decreased in both groups. The hippotherapy group had a greater decrease in sway path lengths (from 236.1 mm at baseline to 182.6 mm) than the treadmill group (from 235.5 mm at baseline to 210.6), suggesting a modest improvement in static balance with hippotherapy. Araujo et al reported a non-rct with 17 older adults in 2011 and an RCT with 28 participants in 2013. In the 2011 study, 16 hippotherapy sessions led to an improvement in the Timed Up and Go (TUG) test in the hippotherapy group compared both with baseline performance and with controls. Balance on a force platform did not differ significantly between the groups. In the 2013 study, 16 hippotherapy sessions over 8 weeks resulted in greater improvement in the Berg Balance Scale and 30s Chair Stand Test compared with controls, with a trend (p= 0.068) toward greater improvement in the TUG. A prospective U.S. study of 9 older adults (mean age, 76.4 years) found improvements in balance and quality of life when measured with a pretestposttest design. Stroke Lee et al, who had conducted the study in older adults previously described, also reported a small randomized trial of hippotherapy for recovery of gait and balance in 30 patients poststroke.18 Patients were included in the study if they had the ability to walk independently or with a walking aid, spasticity in a paretic lower extremity of less than 2 on the Ashworth Scale, and ability to perform training for more than 30 minutes. Patients were randomly assigned to hippotherapy or treadmill for 30 minutes, 3 days a week, for 8 weeks. At the end of training, gait speed and step length asymmetry ratio were assessed, and balance was measured with the Berg Balance Scale. Results were considered significant if they were at p<0.05. The hippotherapy group showed significant improvements in balance, gait speed, and step length asymmetry, while the treadmill training group improved only in step length asymmetry. Improvements in gait speed and step length asymmetry were significantly greater for the hippotherapy group compared with the control group. Other Silkwood-Sherer et al reported on the efficacy of hippotherapy in a convenience sample of 16 children with mild to moderate balance deficits secondary to a variety of disorders. The most common diagnoses were cerebral palsy (n=5), Down syndrome (n=3), developmental coordination disorder (n=2), and autism (n=2). Baseline and posttreatment Pediatric Balance Scale tests were videotaped and sent in a randomized order to 3 pediatric physical therapists for scoring. The Activities Scale for Kids Page 5 of 9

Performance questionnaires were completed by the children or their parents. Hippotherapy sessions, conducted twice weekly for 6 weeks yielded significant improvements on the Pediatric Balance Scale (from a median of 49.0 to 53.0) and the Activities Scale for Kids Performance (from a median of 81.7 to 92.1). This study is limited by the lack of a control group. Giagazoglou et al reported the effect of hippotherapy on balance and strength in a controlled trial of 19 adolescents with intellectual disability. Balance and strength were assessed with a pressure platform before and after 10 weeks of hippotherapy (n=10) and at the same time points in the nonintervention control group (n=9). There were no significant differences between the groups in double leg stance or left leg stance; however, there were significant group-by-time interactions in balance with the right leg stance. Measures of strength were improved following hippotherapy, with significant group-by-time interactions. This study is limited by the lack of an active therapy control group. Another small study of 12 patients with spastic spinal cord injury found hippotherapy to result in short- term improvements in spasticity and well-being. Ongoing and Unpublished Clinical Trials Bunketorp Kall et al have reported an ongoing randomized trial of hippotherapy in the late recovery phase following stroke (NCT01372059). The study has an expected enrollment of 123 patients with an estimated completion date of March 2015. Summary of Evidence Literature on hippotherapy is limited, primarily consisting of uncontrolled case series and small controlled trials from outside the United States. In the largest randomized trial conducted to date (72 children), hippotherapy was found to have no clinically significant impact on children with cerebral palsy. Two small trials from departments of hippotherapy and rehabilitation science in Asia have compared hippotherapy with treadmill training in older adults and in post-stroke patients. These trials show some advantage over treadmill training. Independent replication and comparison with other established treatments for stroke rehabilitation are needed. Hippotherapy for other indications has been compared primarily with no intervention and has not been shown to be more effective than other active therapies. Therefore, the treatment is considered investigational. Reference Resources 1.Snider L, Korner-Bitensky N, Kammann C, et al. Horseback riding as therapy for children with cerebral palsy: is there evidence of its effectiveness? Phys Occup Ther Pediatr. 2007;27(2):5-23. PMID 17442652 2. Sterba JA. Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy? Dev Med Child Neurol. Jan 2007;49(1):68-73. PMID 17209981 3. Johnson CC. The benefits of physical activity for youth with developmental disabilities: a systematic review. Am J Health Promot. Jan-Feb 2009;23(3):157-167. PMID 19149420 4. 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):684-691. PMID 21729249 Page 6 of 9

5. 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. May 26 2012. PMID 22630812 6. 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):111-119; discussion 188. PMID 19191844 7. 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. June 2009;90(6):966-974. PMID 19480872 8. Sterba JA, Rogers BT, France AP, et al. Horseback riding in children with cerebral palsy: effect on gross motor function. Dev Med Child Neurol. May 2002;44(5):301-308. PMID 12033715 9. Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy). J Altern Complement Med. Dec 2003;9(6):817-825. PMID 14736353 10. Shurtleff TL, Standeven JW, Engsberg JR. Changes in dynamic trunk/head stability and functional reach after hippotherapy. Arch Phys Med Rehabil. Jul 2009;90(7):1185-1195. PMID 19577032 11. 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):347-353. PMID 20927000 12. Silkwood-Sherer D, 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. PMID 17558361 13. 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. Oct-Dec 2011;33(4):462-467. PMID 22452106 14. 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. PMID 24567669 15. Araujo TB, Silva NA, Costa JN, et al. Effect of equine-assisted therapy on the postural balance of the elderly. Rev Bras Fisioter. Sep-Oct 2011;15(5):414-419. PMID 22002189 16. de Araujo TB, de Oliveira RJ, Martins WR, et al. Effects of hippotherapy on mobility, strength and balance in elderly. Arch Gerontol Geriatr. May-Jun 2013;56(3):478-481. PMID 23290005 17. 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. PMID 23360659 18. 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. PMID 24648655 19. 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. PMID 22247403 20. 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. Nov 2012;33(6):2265-2270. PMID 22853887 Page 7 of 9

21. Lechner HE, Kakebeeke TH, Hegemann D, et al. The effect of hippotherapy on spasticity and on mental wellbeing of persons with spinal cord injury. Arch Phys Med Rehabil. Oct 2007;88(10):1241-1248. PMID 17908564 22. 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. 2012;12:141. PMID 23171380 Document Precedence Blue Cross and Blue Shield of Vermont (BCBSVT) Medical Policies are developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, BCBSVT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract language, the member s contract language takes precedence. Audit Information BCBSVT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, BCBSVT reserves the right to recoup all non-compliant payments. Administrative and Contractual Guidance Benefit Determination Guidance Coverage varies according to the member s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict. If the member receives benefits through a self-funded (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the member s plan documents or contact the customer service department. Page 8 of 9

Policy Implementation/Update information 07/2011 New Policy Added Document Precedence section. Updated Related Policies section to reflect ECDD medical policy. Minor format changes. Cross 08/2012 referenced all CPT/HCPCS codes to ECDD medical policy, revised/added new coding table. Added Audit Information section. RLJ. 03/2015 Adoption of BCBSA policy# 08.03.12. Approved in MPC on 3/9/15. Approved by BCBSVT Medical Directors Date Approved Joshua Plavin, MD Senior Medical Director Chair, Medical Policy Committee Robert Wheeler MD Chief Medical Officer Attachment I CPT & HCPCS Coding Table Code Type Number Description These services will deny as Not Medically Necessary for all diagnoses. These codes should NOT be used for Hippotherapy or Recreational Therapy CPT 97039 Unlisted modality, (specify type and time if constant attendance) CPT 97139 Unlisted therapeutic procedure (specify) CPT 97799 Unlisted physical medicine/rehabilitation service or procedure The following codes will be denied as Investigational for all diagnoses HCPCS S8940 Equestrian / hippotherapy, per session Page 9 of 9