Medicare Advantage

Medical Policy

Title:

Biofeedback Therapy

Policy #:

MA07.010c

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
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.

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 is not a treatment, per se, but a tool to help individuals learn how to perform pelvic muscle exercise (PME). Biofeedback-assisted PME incorporates the use of an electronic or mechanical device to relay visual and/or auditory evidence of pelvic floor muscle tone, in order to improve awareness of pelvic floor musculature and to assist individuals in the performance of PME.

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 & 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 February 8, 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 February 8, 2024.

Coding

CPT Procedure Code Number(s)

90901, 90912, 90913

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:

4/1/2024

Version Issued Date:

6/17/2024

Version Reissued Date: