Medical Policy Bulletin

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Title:

Biofeedback Therapy

Policy #:

07.00.01d

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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. 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.

Intent

The intent of this policy is to communicate the medical necessity criteria for biofeedback therapy. For information on policies related to this topic, refer to the Cross References Table in this policy.

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. 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. The physician or therapist uses the biofeedback software to guide the individual through a series of exercises designed to re-learn bladder or bowel sensation and control. 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.

Policy

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 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 Patient instruction (eg, practice and follow-through) Frequency of treatment (eg, two times per week) 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 (eg, practice and follow-through at home). The individual is capable of participating in the treatment plan (physically and cognitively). The condition is able to be appropriately treated with biofeedback (ie, there is no pathology to prevent success of the treatment). All other uses for biofeedback therapy are considered not medically necessary and, therefore, not covered because the available published literature does not support their use in the diagnosis or treatment of illness or injury. Biofeedback therapy sessions are limited to 24 visits per 12-month calendar year for single or combination medical condition(s). Sessions beyond these limits are considered not medically necessary and, therefore, not covered. Individual benefits must be verified as some groups exclude coverage for biofeedback therapy. Devices used in biofeedback therapy (eg, electromyography [EMG], biofeedback device) in the office or outpatient setting are not eligible for separate reimbursement since they are inherent to the biofeedback service. The following are not eligible for reimbursement: Group biofeedback education training (ie, more than one individual involved with a practitioner in training) Home use of biofeedback therapy and devices (eg, EMG, biofeedback device) 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 health care professional'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. MEDICARE This policy is consistent with Medicare's coverage determination. 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 Providers should report the diagnosis code for spasm of the muscle (728.85) only when the spasm is related to a documented functional deficit that includes incontinence and/or constipation. Biofeedback therapy is typically performed in the office setting. On the same day that biofeedback therapy is performed, an individual's condition or symptoms may require a significant, separately identifiable evaluation and management (E&M) service above and beyond biofeedback. When biofeedback therapy is performed on the same date of service as an E&M service, the provider should report Modifier 25 to indicate that the E&M was a separate and distinct service from the biofeedback therapy. Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 30.1: Biofeedback therapy. [CMS Web site]. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=30.1&ncd_version=1&basket=ncd%3A30%2E1%3A1%3ABiofeedback+Therapy. Accessed February 27, 2009. 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: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=30.1.1&ncd_version=1&basket=ncd%3A30%2E1%2E1%3A1%3ABiofeedback+Therapy+for+the+Treatment+of+Urinary+Incontinence. Accessed February 27, 2009. 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. 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. 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: http://www.fda.gov/cdrh/pdf5/K050483.pdf. Accessed February 27, 2009. 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 Table

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.

Code System	Code Number(s) and Narrative(s)
CPT	90901, 90911
ICD Procedure	N/A
ICD Diagnosis	564.6: Anal spasm 596.55: Detrusor sphincter dyssynergia 618.83: Pelvic muscle wasting 625.6: Female stress incontinence 728.85: Spasm of muscle 787.6: Incontinence of feces 788.30: Unspecified urinary incontinence 788.31: Urge incontinence 788.32: Stress incontinence, male 788.33: Mixed incontinence urge and stress (male)(female) TO REPORT BIOFEEDBACK FOR THE TREATMENT OF CONSTIPATION SECONDARY TO PROVEN NEUROMUSCULAR PELVIC FLOOR DYSFUNCTION, USE THE FOLLOWING CODE 728.2: Muscular wasting and disuse atrophy, not elsewhere classified
HCPCS Level II	THE FOLLOWING CODE IS NOT COVERED AND NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT CONSIDERATION E0746: Electromyography (EMG), biofeedback device
Revenue Codes	2105: Alternative therapy - Biofeedback

Cross References

Version Effective Date: 07/31/2007