Medicare Advantage

Medical Policy

Title:

Biofeedback Therapy

Policy #:

MA07.010a

Policy

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

NOT MEDICALLY NECESSARY

Biofeedback therapy is considered not medically necessary and, therefore, not covered for the treatment of ordinary muscle tension states or for psychosomatic conditions.

This policy does not address biofeedback therapy for the treatment of urinary or fecal incontinence.

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

This policy is consistent with Medicare's coverage determination for Biofeedback Therapy. The Company's reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, biofeedback is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Description

Biofeedback therapy provides visual, auditory, or other evidence of the status of certain body functions so that a person can exert voluntary control over the functions, and thereby alleviate an abnormal bodily condition. Biofeedback therapy often uses electrical devices to transform bodily signals indicative of such functions as heart rate, blood pressure, skin temperature, salivation, peripheral vasomotor activity, and gross muscle tone into a tone or light, the loudness or brightness of which shows the extent of activity in the function being measured.

Biofeedback therapy differs from electromyography, which is a diagnostic procedure used to record and study the electrical properties of skeletal muscle. An electromyography device may be used to provide feedback with certain types of biofeedback.

References

Centers for Medicare and 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 May 24, 2022.

Coding

CPT Procedure Code Number(s)

90901, 97112

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

2105 Alternative Therapy Services-Biofeedback

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

10/6/2017

Version Issued Date: