Medical Policy


Subject:Hippotherapy
Policy #:  REHAB.00003Current Effective Date:  06/28/2016
Status:ReviewedLast Review Date:  05/05/2016

Description/Scope

This document addresses hippotherapy, also referred to as equine movement therapy, which has been proposed as a type of physical, occupational, or speech and language therapy.  This treatment strategy utilizes equine movement for individuals with impaired movement related to autism spectrum disorders, spastic cerebral palsy and other motor dysfunctions.

Position Statement

Investigational and Not Medically Necessary:

Hippotherapy is considered investigational and not medically necessary in all cases.

Rationale

There is insufficient scientific data in the peer-reviewed medical literature to support the effectiveness of hippotherapy for any indication, including but not limited to the treatment of individuals with autism spectrum disorders, cerebral palsy or other motor dysfunction such as arthritis, multiple sclerosis, head injury, and stroke.

The majority of the literature regarding hippotherapy consists of small case series published in the German literature. English language publications also consist of small case series (Benda, 2003; McGibbon, 1998). Sterba and colleagues (2002) 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. This small trial is inadequate to permit scientific conclusions.

In 2015, Kwon and colleagues reported results from a randomized controlled trial of children (4-10 years old) with cerebral palsy. A total of 91 subjects were randomized to the intervention group with hippotherapy 3 minutes twice weekly (n=45) or the control group with home-based aerobic exercise (n=46) for a total of 8 consecutive weeks. The Baseline Gross Motor Function Measure (GMFM) (GMFM-66 and GMFM-88) total and dimension scores did not significantly differ between groups. The initial short term benefits of hippotherapy in children with cerebral palsy shows promise, although further studies are needed to assess the maintenance effect of hippotherapy over time.

An updated literature search based on the MEDLINE database through March 2016 did not identify any new literature to support the use of hippotherapy for those with autism spectrum disorders, spastic cerebral palsy and other motor dysfunctions.

Background/Overview

Hippotherapy, also referred to as equine movement therapy, describes a form of physical, occupational or speech and language therapy using horses. It is a form of therapeutic horseback riding or equestrian therapy. This treatment strategy 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 also prompt natural equilibrium movements in the rider. To attain specific postural responses, the therapist may place the rider in different positions on the horse, such as sitting, side sitting, prone or side lying. In many cases, the therapist will ride with the rider in order to facilitate the movement or desired response.

Hippotherapy has also been proposed as a therapeutic treatment for other disorders or conditions such as traumatic brain injury, stroke, multiple sclerosis, autism, spina bifida, learning disabilities, and mental retardation.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the following procedure code in all instances, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

HCPCS 
S8940Equestrian/hippotherapy, per session
  
ICD-10 Diagnosis 
 All diagnoses
  
References

Peer Reviewed Publications:

  1. Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy). J Altern Complement Med. 2003; 9(6):817-825.
  2. Keren O, Reznik J, Groswasser Z. Combined motor disturbances following severe traumatic brain injury: an integrative long-term approach. Brain Inj. 2001; 15(7):633-638.
  3. Kern JK, Fletcher CL, Garver CR, et al. Prospective trial of equine-assisted activities in autism spectrum disorder. Altern Ther Health Med. 2011; 17(3):14-20.
  4. Kim SG, Lee CW. The effects of hippotherapy on elderly persons' static balance and gait. J Phys Ther Sci. 2014; 26:25-27.
  5. 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. 2015; 21(1):15-21.
  6. Lechner HE, Kakebeeke TH, Hegemann D, Baumberger M. The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury. Arch Phys Med Rehabil. 2007; 88(10):1241-1248.
  7. Lee CW, Kim SG, Yong MS. Effects of hippotherapy on recovery of gait and balance ability in patients with stroke. J Phys Ther Sci. 2014; 26:309-311.
  8. McGibbon NH, Andrade CK, Widener G, Cintas HL. Effect of an equine-movement therapy program on gait, energy expenditure, and motor function in children with spastic cerebral palsy: a pilot study. Dev Med Child Neurol. 1998; 40(11):754-762.
  9. Meregillano G. Hippotherapy. Phys Med Rehabil Clin N Am. 2004; 15(4):843-854.
  10. Silkwood-Sherer DJ, Killian CB, Long TM, Martin KS. Hippotherapy- an intervention to habilitate balance deficits in children with movement disorders: a clinical trial. Physical Therapy. 2013; 92(5):707-717.
  11. Sterba JA. Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy? Dev Med Child Neurol. 2007; 49(1):68-73.
  12. Sterba JA, Rogers BT, France AP, Vokes DA. Horseback riding in children with cerebral palsy: effect on gross motor function. Dev Med Child Neurol. 2002; 44:301-308.
Websites for Additional Information
  1. American Hippotherapy Association. Hippotherapy as a Treatment Strategy. Available at: http://www.americanhippotherapyassociation.org/hippotherapy/hippotherapy-as-a-treatment-strategy/. Accessed on March 4, 2016.
  2. Professional Association of Therapeutic Horsemanship International (PATH Intl.). What is PATH Intl.? Available at: http://www.pathintl.org/about-path-intl/about-path-intl. Accessed on March 4, 2016.
Index

Equestrian Therapy
Equine Movement Therapy
Hippotherapy
Horseback Riding Therapy

Document History

Status

Date

Action

Reviewed05/05/2016Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale, References and Websites sections. Removed ICD-9 codes from Coding section.
Reviewed05/07/2015MPTAC review. Updated Description, Rationale and References sections.
Reviewed05/15/2014MPTAC review. Updated Description, Background, and Websites.
Reviewed05/09/2013MPTAC review. Updated References and Websites.
Reviewed05/10/2012MPTAC review.  Updated references and websites.
Reviewed05/19/2011MPTAC review. Updated references and websites.
Reviewed05/12/2010MPTAC review. Updated references and websites.
Reviewed05/21/2009MPTAC review.  Updated references.
Reviewed05/15/2008MPTAC review. Updated review date, references and history sections of document.
 02/21/2008The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed05/17/2007MPTAC review. References updated. 
Reviewed06/08/2006MPTAC review. Updated references. No change to document stance.
Revised07/14/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

06/11/2001

REHAB.00003Hippotherapy
WellPoint Health Networks, Inc.

12/04/2003

10.01.13Equine Movement Therapy (Hippotherapy)