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Biofeedback Therapy
07.00.01l

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
  • 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

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 Psychphysiology and Biofeedback I. Standards for Performing Biofeedback. 2013; 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. Diseases of the 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 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 March 22, 2024.

Centers for Medicare and 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. Sep 2019; 4(9): 698-710. PMID 31320277.


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. 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 March 22, 2024.

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)
90901, 90912, 90913, 97112

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
G43.001Migraine without aura, not intractable, with status migrainosus
G43.009Migraine without aura, not intractable, without status migrainosus
G43.011Migraine without aura, intractable, with status migrainosus
G43.019Migraine without aura, intractable, without status migrainosus
G43.101Migraine with aura, not intractable, with status migrainosus
G43.109Migraine with aura, not intractable, without status migrainosus
G43.111Migraine with aura, intractable, with status migrainosus
G43.119Migraine with aura, intractable, without status migrainosus
G43.401Hemiplegic migraine, not intractable, with status migrainosus
G43.409Hemiplegic migraine, not intractable, without status migrainosus
G43.411Hemiplegic migraine, intractable, with status migrainosus
G43.419Hemiplegic migraine, intractable, without status migrainosus
G43.501Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus
G43.509Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus
G43.511Persistent migraine aura without cerebral infarction, intractable, with status migrainosus
G43.519Persistent migraine aura without cerebral infarction, intractable, without status migrainosus
G43.601Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus
G43.609Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus
G43.611Persistent migraine aura with cerebral infarction, intractable, with status migrainosus
G43.619Persistent migraine aura with cerebral infarction, intractable, without status migrainosus
G43.701Chronic migraine without aura, not intractable, with status migrainosus
G43.709Chronic migraine without aura, not intractable, without status migrainosus
G43.711Chronic migraine without aura, intractable, with status migrainosus
G43.719Chronic migraine without aura, intractable, without status migrainosus
G43.801Other migraine, not intractable, with status migrainosus
G43.809Other migraine, not intractable, without status migrainosus
G43.811Other migraine, intractable, with status migrainosus
G43.819Other migraine, intractable, without status migrainosus
G43.821Menstrual migraine, not intractable, with status migrainosus
G43.829Menstrual migraine, not intractable, without status migrainosus
G43.831Menstrual migraine, intractable, with status migrainosus
G43.839Menstrual migraine, intractable, without status migrainosus
G43.901Migraine, unspecified, not intractable, with status migrainosus
G43.909Migraine, unspecified, not intractable, without status migrainosus
G43.911Migraine, unspecified, intractable, with status migrainosus
G43.919Migraine, unspecified, intractable, without status migrainosus
​G43.E01
​Chronic migraine with aura, not intractable, with status migrainosus
G43.E09Chronic migraine with aura, not intractable, without status migrainosus
G43.E11Chronic migraine with aura, intractable, with status migrainosus
G43.E19Chronic migraine with aura, intractable, without status migrainosus
G44.201Tension-type headache, unspecified, intractable
G44.209Tension-type headache, unspecified, not intractable
G44.211Episodic tension-type headache, intractable
G44.219Episodic tension-type headache, not intractable
G44.221Chronic tension-type headache, intractable
G44.229Chronic tension-type headache, not intractable
K59.4Anal spasm
M26.601Right temporomandibular joint disorder, unspecified
M26.602Left temporomandibular joint disorder, unspecified
M26.603Bilateral temporomandibular joint disorder, unspecified
M26.609Unspecified temporomandibular joint disorder, unspecified side
M26.611Adhesions and ankylosis of right temporomandibular joint
M26.612Adhesions and ankylosis of left temporomandibular joint
M26.613Adhesions and ankylosis of bilateral temporomandibular joint
M26.619Adhesions and ankylosis of temporomandibular joint, unspecified side
M26.621Arthralgia of right temporomandibular joint
M26.622Arthralgia of left temporomandibular joint
M26.623Arthralgia of bilateral temporomandibular joint
M26.629Arthralgia of bilateral temporomandibular joint
M26.631Articular disc disorder of right temporomandibular joint
M26.632Articular disc disorder of left temporomandibular joint
M26.633Articular disc disorder of bilateral temporomandibular joint
M26.639Articular disc disorder of temporomandibular joint, unspecified side 
M26.641Arthritis of right temporomandibular joint 
M26.642Arthritis of left temporomandibular joint 
M26.643Arthritis of bilateral temporomandibular joint 
M26.649Arthritis of unspecified temporomandibular joint 
M26.651Arthropathy of right temporomandibular joint 
M26.652Arthropathy of left temporomandibular joint 
M26.653Arthropathy of bilateral temporomandibular joint 
M26.659Arthropathy of unspecified temporomandibular joint    ​​
M26.69Other specified disorders of temporomandibular joint
M62.411Contracture of muscle, left shoulder
M62.412Contracture of muscle, right shoulder
M62.419Contracture of muscle, unspecified shoulder
M62.421Contracture of muscle, right upper arm
M62.422Contracture of muscle, left upper arm
M62.429Contracture of muscle, unspecified upper arm
M62.431Contracture of muscle, right forearm
M62.432Contracture of muscle, left forearm
M62.439Contracture of muscle, unspecified forearm
M62.441Contracture of muscle, right hand
M62.442Contracture of muscle, left hand
M62.449Contracture of muscle, unspecified hand
M62.451Contracture of muscle, right thigh
M62.452Contracture of muscle, left thigh
M62.459Contracture of muscle, unspecified thigh
M62.461Contracture of muscle, right lower leg
M62.462Contracture of muscle, left lower leg
M62.469Contracture of muscle, unspecified lower leg
M62.471Contracture of muscle, right ankle and foot
M62.472Contracture of muscle, left ankle and foot
M62.479Contracture of muscle, unspecified ankle and foot
M62.48Contracture of muscle, other site
M62.49Contracture of muscle, multiple sites
M62.50Muscle wasting and atrophy, not elsewhere classified, unspecified site
M62.511Muscle wasting and atrophy, not elsewhere classified, right shoulder
M62.512Muscle wasting and atrophy, not elsewhere classified, left shoulder
M62.521Muscle wasting and atrophy, not elsewhere classified, right upper arm
M62.522Muscle wasting and atrophy, not elsewhere classified, left upper arm
M62.531Muscle wasting and atrophy, not elsewhere classified, right forearm
M62.532Muscle wasting and atrophy, not elsewhere classified, left forearm
M62.541Muscle wasting and atrophy, not elsewhere classified, right hand
M62.542Muscle wasting and atrophy, not elsewhere classified, left hand
M62.551Muscle wasting and atrophy, not elsewhere classified, right thigh
M62.552Muscle wasting and atrophy, not elsewhere classified, left thigh
M62.561Muscle wasting and atrophy, not elsewhere classified, right lower leg
M62.562Muscle wasting and atrophy, not elsewhere classified, left lower leg
M62.571Muscle wasting and atrophy, not elsewhere classified, right ankle and foot
M62.572Muscle wasting and atrophy, not elsewhere classified, left ankle and foot
M62.59Muscle wasting and atrophy, not elsewhere classified, multiple sites
M62.81Muscle weakness (generalized)
M62.830Muscle spasm of back
M62.831Muscle spasm of calf
M62.838Other muscle spasm
N36.44Muscular disorders of urethra
N39.3Stress incontinence (female) (male)
N39.41Urge incontinence
N39.46Mixed incontinence
N81.84Pelvic muscle wasting
R15.0Incomplete defecation
R15.1Fecal smearing
R15.2Fecal urgency
R15.9Full incontinence of feces
R32Unspecified urinary incontinence 


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

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

HCPCS Level II Code Number(s)
S9002 Intra-vaginal 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

4/1/2024
4/2/2024
07.00.01
Medical Policy Bulletin
Commercial
No