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Biofeedback Therapy
07.00.01n

Policy

MEDICALLY NECESSARY

Biofeedback therapy is considered medically necessary and, therefore, covered for any of the following situations:
  • 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 co​ntinence after completing 4 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 two to three visits per week for 6 to 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.

Electroencephalogram biofeedback (i.e., neurofeedback) for all indications 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 FDA for biofeedback therapy.

BILLING GUIDELINES
​
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

Description

BIOFEEDBACK THERAPY

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 physiologic​ 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 two to three 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.

ELECTROENCEPHALOGRAM (EEG) BIOFEEDBACK (NEUROFEEDBACK)


Neurofeedback is being investigated for the treatment of a variety of psychiatric, central nervous system, and pain disorders, but it has namely been researched as a treatment for attention-deficit/hyperactivity disorder (ADHD). Neurofeedback may be conceptualized as a type of biofeedback that has traditionally used the EEG as a source of feedback data. Neurofeedback differs from established forms of biofeedback in that the information fed back to the individual (via EEG tracings, functional magnetic resonance imaging, near-infrared spectroscopy) is a direct measure of global neuronal activity, or brain state, compared with feedback of the centrally regulated physiologic processes, such as tension of specific muscle groups or skin temperature. The individual may be trained to increase or decrease the prevalence, amplitude, or frequency of specified EEG waveforms (e.g., alpha, beta, theta waves), depending on the changes in brain function associated with the particular disorder. It has been proposed that training of slow cortical potentials (SCPs) can regulate cortical excitability and that using the EEG as a measure of central nervous system functioning can help train individuals to modify or control their abnormal brain activity. Upregulating or downregulating neural activity with real-time feedback of functional magnetic resonance imaging signals is also being explored.


For individuals who have attention-deficit/hyperactivity disorder (ADHD) who receive neurofeedback, the evidence includes randomized controlled trials (RCTs) and meta-analyses. Relevant outcomes are symptoms, functional outcomes, and quality of life. Several meta-analyses and at least five additional moderately sized RCTs (n range, 144 to 202 patients) have compared neurofeedback with methylphenidate, biofeedback, cognitive behavioral therapy, cognitive training, physical activity, or sham neurofeedback. Collectively, these studies found either small or no benefit of neurofeedback. A meta-analysis also found no effect of neurofeedback on objective measures of attention and inhibition. Studies that used active controls have suggested that at least part of the effect of neurofeedback may be due to attention skills training, relaxation training, and/or other nonspecific effects. Also, the beneficial effects of neurofeedback are more likely to be reported by evaluators unblinded to treatment (parents) than by evaluators blinded to treatment (teachers), suggesting bias in the nonblinded evaluations. Additional research with blinded evaluation of outcomes is needed to demonstrate the effect of neurofeedback on ADHD. However, the completion dates for some registered trials of neurofeedback in ADHD have passed without publication of results, suggesting the potential for publication bias. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.​

For individuals who have other disorders (e.g., chronic insomnia, epilepsy, substance abuse, pediatric brain tumors, and post-traumatic stress disorder) who receive neurofeedback, the evidence includes case reports, case series, comparative cohorts, small RCTs, and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and quality of life. For these other disorders, including psychiatric, neurologic, and pain syndromes, the evidence is poor, and several questions concerning clinical efficacy remain unanswered. Larger RCTs that include either a sham or active control are needed to evaluate the effect of neurofeedback for these conditions. However, the completion dates for some registered trials of neurofeedback in other disorders have passed without publication of results, suggesting the potential for publication bias. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.​

References

Armstrong C, American Academy of Neurology, American Headache Society. AAN/AHS update recommendations for migraine prevention in adults. Am Fam Physician. 2013;87(8):584-585.

Association for Applied Psychophysiology ​and Biofeedback I. Standards for Performing Biofeedback. 2013. Available at: https://aapb.org/Standards_for_Performing_Biofeedback. Accessed March 22, 2024.

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 March 22, 2024.

Bordeianou LG, Thorsen AJ, Keller DS, et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2023;66:647-661.

Busse JW, Casassus R, Carrasco-Labra A, et al. Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline. BMJ. 2023;383:e076227. Published 2023 Dec 15. doi:10.1136/bmj-2023-076227.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 30.1 Biofeedback Therapy [CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=41&ncdver=1&DocID=30.1&bc=gAAAABAAAAAA&. Accessed March 22, 2024.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence [CMS Web site]. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=42&ncdver=1. Accessed March 22, 2024.

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.

Jelovsek JE, Markland AD, Whitehead WE, et al. Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial. Lancet Gastroenterol Hepatol. 2019;4(9):698-710.

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 Neurologic Disorders and Stroke. Headache information page. April 22, 2022; https://www.ninds.nih.gov/health-information/disorders/headache. Accessed March 22, 2024.

National Institute of Dental and Craniofacial Research. National Institutes of Health. TMJ disorders. January 2022. Available at: https://www.nidcr.nih.gov/health-info/tmd. Accessed March 22, 2024.

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.

Okeson JP. Temporomandibular disorders. In: Bope ET, Kellerman R, Rakel RE, eds. Conn's 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. Dis 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.

Renovia, Inc. Renovia receives Breakthrough Device Designation for Ieva®​ digital therapeutic as first-line treatment for chronic fecal incontinence. Available at: https://www.prnewswire.com/news-releases/renovia-receives-breakthrough-device-designation-for-leva-digital-therapeutic-as-first-line-treatment-for-chronic-fecal-incontinence-301411847.html. Accessed July 18, 2022.

Rosenblatt P, McKinney J, Rosenberg RA, et al. Evaluation of an accelerometer-based digital health system for the treatment of female urinary incontinence: a pilot study. Neurourol Urodyn. 2019:38(7):1944-1952.

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.pdfhttps. Accessed March 22, 2024.

Weinstein MM, Collins S, Quiroz L, et al. Multicenter randomized controlled trial of pelvic floor muscle training with a motion-based digital therapeutic device versus pelvic floor muscle training alone for treatment of stress-predominant urinary incontinence. Female Pelvic Med Reconstr Surg. 2022;28(1):1-6.

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

CPT Procedure Code Number(s)
MEDICALLY NECESSARY

90901, 90912, 90913

EXPERIMENTAL/INVESTIGATIONAL

90875, 90876
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
G43.001Migraine 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

G43.E01 Chronic migraine with aura, not intractable, with status migrainosus

G43.E09 Chronic migraine with aura, not intractable, without status migrainosus

G43.E11 Chronic migraine with aura, intractable, with status migrainosus

G43.E19 Chronic migraine with aura, 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

M26.611 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

M26.621 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

M26.641 Arthritis of right temporomandibular joint

M26.642 Arthritis of left temporomandibular joint

M26.643 Arthritis of bilateral temporomandibular joint

M26.651 Arthropathy of right temporomandibular joint

M26.652 Arthropathy of left temporomandibular joint

M26.653 Arthropathy of bilateral temporomandibular joint

M26.69 Other specified disorders of temporomandibular joint

M62.411 Contracture of muscle, left shoulder

M62.412 Contracture of muscle, right shoulder

M62.421 Contracture of muscle, right upper arm

M62.422 Contracture of muscle, left upper arm

M62.431 Contracture of muscle, right forearm

M62.432 Contracture of muscle, left forearm

M62.441 Contracture of muscle, right hand

M62.442 Contracture of muscle, left hand

M62.451 Contracture of muscle, right thigh

M62.452 Contracture of muscle, left thigh

M62.461 Contracture of muscle, right lower leg

M62.462 Contracture of muscle, left 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

M62.511 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

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

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

M62.81 Muscle weakness (generalized)

M62.830 Muscle spasm of back

M62.831 Muscle spasm of calf

M62.838 Other muscle spasm

M62.89 Other specified disorders of muscle

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​​
HCPCS Level II Code Number(s)
EXPERIMENTAL/INVESTIGATIONAL

S9002 Intravaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device

Revenue Code Number(s)
2105 Alternative therapy Services-Biofeedback


Coding and Billing Requirements

Policy History

7/1/2024
7/15/2024
07.00.01
Medical Policy Bulletin
Commercial
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.