This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.
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
- The individual has 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 4 weeks of an ordered regimen of PMEs.
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.
NOT COVERED
Home use of biofeedback is not covered by the Company because it is not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.
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.