Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Biofeedback Therapy

Policy #:07.00.01h

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Biofeedback therapy is considered medically necessary and, therefore, covered for any of the following when a documented functional deficit is present:
  • Muscle re-education of specific muscle groups
  • Treatment of incapacitating muscle spasm and/or weakness
  • Treatment of pathological muscle abnormalities when conventional treatments (heat/cold massage, exercise, support) have not been successful
  • Treatment of stress and/or urge urinary incontinence in cognitively intact individuals who have failed a documented trial of pelvic muscle exercise (PME) training designed to increase periurethral muscle strength
    • Failure is defined as no clinically significant improvement in urinary continence after completing four weeks of an ordered regimen of PMEs
  • Treatment of constipation secondary to proven neuromuscular pelvic floor dysfunction
  • Treatment of fecal incontinence
  • Treatment of migraine and tension-type headache
  • Treatment of temporomandibular joint disorder (TMD)

When biofeedback therapy is performed for any of the reasons listed above, the individual's medical records must document an ongoing treatment plan, which includes the following:
  • Diagnosis
  • Frequency goals
  • Individual instruction (e.g., practice and follow-through)
  • Frequency of treatment (e.g., two times per week)

If the professional provider has determined that the individual does not appear to be benefitting from biofeedback or moving toward individual treatment goals after 4 weeks of biofeedback therapy, the use of biofeedback should be re-evaluated and the professional provider should suggest an alternative treatment plan.

Biofeedback treatment is medically necessary and, therefore, covered up to 2-3 visits per week for 6-8 weeks for single or combination medical condition(s). Sessions provided beyond this are considered not medically necessary, and, therefore, not covered.

In addition, the individual's medical records must document that all of the following criteria have been met:
  • The individual is motivated to actively participate in the treatment plan and is responsive to the care plan requirements (e.g., practice and follow-through at home).
  • The individual is capable of participating in the treatment plan (physically and cognitively).
  • The condition can be appropriately treated with biofeedback (i.e., there is no pathology to prevent success of the treatment).

EXPERIMENTAL/INVESTIGATIONAL

Biofeedback therapy for all other uses is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, biofeedback therapy is covered under the medical benefits of the Company's products when the medical necessity criteria listed in the medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the US Food and Drug Administration (FDA) for biofeedback therapy.

BILLING GUIDELINES

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The following are not eligible for reimbursement:
  • Group biofeedback education training (i.e., more than one individual involved with a practitioner in training)
  • Home use of biofeedback therapy and devices (e.g., EMG, biofeedback device)

Description

Biofeedback therapy is a training technique that provides visual, auditory, or other evidence of the status of certain bodily functions so that a person can exert voluntary control over the functions and alleviate deficits. The term biofeedback refers to the biological signals that are fed back, or returned, to the individual to assist in developing techniques for manipulating or controlling specific bodily functions for the purposes of improving health and performance.

Biofeedback therapy is used for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, when more conventional treatments (e.g. heat, cold, massage, exercise, support) have not been successful.

Anatomically, a network of pelvic floor muscles is instrumental in maintaining bowel and bladder control. These muscles can lose their ability to work properly for any number of reasons, including, but not limited to, the natural aging process, childbirth, diabetes, prostate surgery, chronic constipation, and/or excessive muscle tension. Specialized sensors and biofeedback instruments are used to determine the individual's initial control and muscle strength. Biofeedback software is used to guide the individual through a series of exercises designed to re-learn bladder or bowel sensation and control.

Biofeedback therapy is used for the treatment and prevention of migraine and tension-type headaches. Review of the available published peer-reviewed literature and professional society guidelines support biofeedback as an effective treatment in reducing the severity and frequency of migraine and tension-type headaches when included in a comprehensive treatment program.

Biofeedback therapy is also used in the treatment of temporomandibular joint disorder (TMD). It is one of an array of conservative treatment options available to help an individual with TMD to consciously control physicologic functions and has been shown to be useful in managing stress-related disorders and pain.

Biofeedback therapy differs from electromyography (EMG), which is a diagnostic procedure used to record and study the electrical properties of skeletal muscles. However, an EMG device may be used to provide feedback with certain types of biofeedback.

A review of current medical literature indicates that biofeedback is used as an adjunctive service, concurrently provided with a physical therapy program. Depending on the condition being treated, biofeedback is typically provided 2 to 3 times per week for 6 to 8 weeks. Although an individual who responds more quickly to treatment may require less biofeedback therapy, response time can vary if there are existing comorbidities.
References


American Acade upFP. Guidelines on migraine: part 4. General principles of preventive therapy. Am Fam Physician 2000; http://www.aafp.org/afp/2000/1115/p2359.html. Accessed May 7, 2018.

Association for Applied Psychphysiology and Biofeedback I. Standards for Performing Biofeedback. 2013; http://www.aapb.org/i4a/pages/index.cfm?pageid=3678#II. Accessed May 7, 2018.

Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol. 2010;17(11):1318-1325.

Biofeedback. [IFFGD Web site]. 03/24/2016. Available at: https://www.aboutincontinence.org/treatment/biofeedback.html. Accessed May 7, 2018.

Campbell JK, Penzien DB, Wall EM, et al. Evidence-based guidelines for migraine headache: behavioral and physical treatments. US Headache Consortium. 2000;2014 (February). Accessed May 5, 2018. Available at: http://tools.aan.com/professionals/practice/pdfs/gl0089.pdf.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).30.1: Biofeedback therapy. [CMS Web site]. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=41&ncdver=1&bc=AgAAQAAAAAAA&. Accessed May 7, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 30.1.1: Biofeedback therapy for the treatment of urinary incontinence. [CMS Web site]. 07/01/01. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=42&ncdver=1&bc=AgAAQAAAAAAA&. Accessed May 7, 2018.

Chin-Peuckert L, Salle JL. A modified biofeedback program for children with detrusor-sphincter dyssynergia: 5-year experience. J Urol. 2001;166(4):1470-1475.

De Paepe H, Hoebeke P, Renson C, et al. Pelvic-floor therapy in girls with recurrent urinary tract infections and dysfunctional voiding. Br J Urol. 1998;81 Suppl 3:109-113.

Klijn AJ, Uiterwaal CS, Vijverberg MA, et al. Home uroflowmetry biofeedback in behavioral training for dysfunctional voiding in school-age children: A randomized controlled study. J Urol. 2006;175(6):2263-2268.

McKenna PH, Herndon CD, Connery S, Ferrer FA. Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive computer games. J Urol. 1999;162(3 Pt 2):1056-1063.

National Institute of Dental and Craniofacial Research. Natinal Institutes of Health. TMJ disorders. March 2010. March 2011. Available at: http://www.nidcr.nih.gov/OralHealth/Topics/TMJ/. Accessed May 7, 2018.

Nestoriuc Y, Rief W, Martin A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J Consult Clin Psychol. 2008;76(3):379-396.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L34977: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters. [Novitas Solutions, Inc. Web site]. Original 10/01/15. (Revised: 10/01/16). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34977&ver=10&Keyword=biofeedback&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAACAAAAAA&. Accessed May 7, 2018.

Okeson JP. Temporomandibular disorders. In: Bope ET, Kellerman R, Rakel RE, eds. Conns Current Therapy. St. Louis, Mo:Saunders:2011.

Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence. Diseases of the Colon & Rectum. 2015;58 (7)623-636.

Palmer LS, Franco I, Rotario P, et al. Biofeedback therapy expedites the resolution of reflux in older children. J Urol. 2002;168(4 Pt 2):1699-1702.

Porena M, Costantini E, Rociola W, Mearini E. Biofeedback successfully cures detrusor-sphincter dyssynergia in pediatric patients. J Urol. 2000;163(6):1927-1931.

Rotter BE. Temporomandibular joint disorders. In: Flint Pw, Haughey BH, Lund VJ, eds. Cummings Otolaryngology: Head and Neck Surgery. St. Louis, MO:Saunders;2011.

Sadovsky R. Treatment of fecal incontinence in men. Am Fam Phys. 1999; 60(8):2372-2374.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. evadri Bladder Control System. 510(k) Summary. [FDA Web site]. 04/12/05. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf5/k050483.pdf. Accessed May 7, 2018.

Yagci S, Kibar Y, Akay O, et al. The effect of biofeedback treatment on voiding and urodynamic parameters in children with voiding dysfunction. J Urol.2005;174(5):1994-1998.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

90901, 90911, 97112


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

G43.001 Migraine without aura, not intractable, with status migrainosus

G43.009 Migraine without aura, not intractable, without status migrainosus

G43.011 Migraine without aura, intractable, with status migrainosus

G43.019 Migraine without aura, intractable, without status migrainosus

G43.101 Migraine with aura, not intractable, with status migrainosus

G43.109 Migraine with aura, not intractable, without status migrainosus

G43.111 Migraine with aura, intractable, with status migrainosus

G43.119 Migraine with aura, intractable, without status migrainosus

G43.401 Hemiplegic migraine, not intractable, with status migrainosus

G43.409 Hemiplegic migraine, not intractable, without status migrainosus

G43.411 Hemiplegic migraine, intractable, with status migrainosus

G43.419 Hemiplegic migraine, intractable, without status migrainosus

G43.501 Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus

G43.509 Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus

G43.511 Persistent migraine aura without cerebral infarction, intractable, with status migrainosus

G43.519 Persistent migraine aura without cerebral infarction, intractable, without status migrainosus

G43.601 Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus

G43.609 Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus

G43.611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus

G43.619 Persistent migraine aura with cerebral infarction, intractable, without status migrainosus

G43.701 Chronic migraine without aura, not intractable, with status migrainosus

G43.709 Chronic migraine without aura, not intractable, without status migrainosus

G43.711 Chronic migraine without aura, intractable, with status migrainosus

G43.719 Chronic migraine without aura, intractable, without status migrainosus

G43.801 Other migraine, not intractable, with status migrainosus

G43.809 Other migraine, not intractable, without status migrainosus

G43.811 Other migraine, intractable, with status migrainosus

G43.819 Other migraine, intractable, without status migrainosus

G43.821 Menstrual migraine, not intractable, with status migrainosus

G43.829 Menstrual migraine, not intractable, without status migrainosus

G43.831 Menstrual migraine, intractable, with status migrainosus

G43.839 Menstrual migraine, intractable, without status migrainosus

G43.901 Migraine, unspecified, not intractable, with status migrainosus

G43.909 Migraine, unspecified, not intractable, without status migrainosus

G43.911 Migraine, unspecified, intractable, with status migrainosus

G43.919 Migraine, unspecified, intractable, without status migrainosus

G44.201 Tension-type headache, unspecified, intractable

G44.209 Tension-type headache, unspecified, not intractable

G44.211 Episodic tension-type headache, intractable

G44.219 Episodic tension-type headache, not intractable

G44.221 Chronic tension-type headache, intractable

G44.229 Chronic tension-type headache, not intractable

K59.4 Anal spasm

M26.601 Right temporomandibular joint disorder, unspecified

M26.602 Left temporomandibular joint disorder, unspecified

M26.603 Bilateral temporomandibular joint disorder, unspecified

M26.609 Unspecified temporomandibular joint disorder, unspecified side

M26.611 Adhesions and ankylosis of right temporomandibular joint

M26.612 Adhesions and ankylosis of left temporomandibular joint

M26.613 Adhesions and ankylosis of bilateral temporomandibular joint

M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side

M26.621 Arthralgia of right temporomandibular joint

M26.622 Arthralgia of left temporomandibular joint

M26.623 Arthralgia of bilateral temporomandibular joint

M26.629 Arthralgia of bilateral temporomandibular joint

M26.631 Articular disc disorder of right temporomandibular joint

M26.632 Articular disc disorder of left temporomandibular joint

M26.633 Articular disc disorder of bilateral temporomandibular joint

M26.639 Articular disc disorder of temporomandibular joint, unspecified side

M26.69 Other specified disorders of temporomandibular joint

M62.411 Contracture of muscle, left shoulder

M62.412 Contracture of muscle, right shoulder

M62.419 Contracture of muscle, unspecified shoulder

M62.421 Contracture of muscle, right upper arm

M62.422 Contracture of muscle, left upper arm

M62.429 Contracture of muscle, unspecified upper arm

M62.431 Contracture of muscle, right forearm

M62.432 Contracture of muscle, left forearm

M62.439 Contracture of muscle, unspecified forearm

M62.441 Contracture of muscle, right hand

M62.442 Contracture of muscle, left hand

M62.449 Contracture of muscle, unspecified hand

M62.451 Contracture of muscle, right thigh

M62.452 Contracture of muscle, left thigh

M62.459 Contracture of muscle, unspecified thigh

M62.461 Contracture of muscle, right lower leg

M62.462 Contracture of muscle, left lower leg

M62.469 Contracture of muscle, unspecified lower leg

M62.471 Contracture of muscle, right ankle and foot

M62.472 Contracture of muscle, left ankle and foot

M62.479 Contracture of muscle, unspecified ankle and foot

M62.48 Contracture of muscle, other site

M62.49 Contracture of muscle, multiple sites

M62.50 Muscle wasting and atrophy, not elsewhere classified, unspecified site

M62.511 Muscle wasting and atrophy, not elsewhere classified, right shoulder

M62.512 Muscle wasting and atrophy, not elsewhere classified, left shoulder

M62.521 Muscle wasting and atrophy, not elsewhere classified, right upper arm

M62.522 Muscle wasting and atrophy, not elsewhere classified, left upper arm

M62.531 Muscle wasting and atrophy, not elsewhere classified, right forearm

M62.532 Muscle wasting and atrophy, not elsewhere classified, left forearm

M62.541 Muscle wasting and atrophy, not elsewhere classified, right hand

M62.542 Muscle wasting and atrophy, not elsewhere classified, left hand

M62.551 Muscle wasting and atrophy, not elsewhere classified, right thigh

M62.552 Muscle wasting and atrophy, not elsewhere classified, left thigh

M62.561 Muscle wasting and atrophy, not elsewhere classified, right lower leg

M62.562 Muscle wasting and atrophy, not elsewhere classified, left lower leg

M62.571 Muscle wasting and atrophy, not elsewhere classified, right ankle and foot

M62.572 Muscle wasting and atrophy, not elsewhere classified, left ankle and foot

M62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sites

M62.830 Muscle spasm of back

M62.831 Muscle spasm of calf

M62.838 Other muscle spasm

M62.81 Muscle weakness (generalized)

N36.44 Muscular disorders of urethra

N39.3 Stress incontinence (female) (male)

N39.41 Urge incontinence

N39.46 Mixed incontinence

N81.84 Pelvic muscle wasting

R15.0 Incomplete defecation

R15.1 Fecal smearing

R15.2 Fecal urgency

R15.9 Full incontinence of feces

R32 Unspecified urinary incontinence

THE FOLLOWING CODE IS USED TO REPRESENT BIOFEEDBACK FOR THE TREATMENT OF CONSTIPATION SECONDARY TO PROVEN NEUROMUSCULAR PELVIC FLOOR DYSFUNCTION:

M62.58 Muscle wasting and atrophy, not elsewhere classified, other site



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

2105 Alternative therapy Services-Biofeedback

Coding and Billing Requirements


Cross References


Policy History

07.00.01h
06/20/2018Effective 6/20/18, this policy has been reviewed and reissued to communicate the Company’s continuing position on Biofeedback Therapy.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 10/06/2017
Version Issued Date: 10/06/2017
Version Reissued Date: 06/20/2018

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