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

Revisions From MA07.010c:

04/01/2024

The version of the policy will be issued on 06/17/2024 with a retroactively effective date of 04/01/2024.

The following code has been deleted from this policy and is addressed in the

Prescription Digital Therapeutics and Mobile-Based Health Management Applications policy:

S9002

Revisions From MA07.010b:

12/10/2023

The version of the policy will be issued on 04/22/2024 with a retroactive effective date of 12/10/2023.

The following criteria have been added to this policy as medically necessary:

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 four weeks of an ordered regimen of PMEs.

The following criterion has been added to this policy as not covered:

Home use of biofeedback

The following CPT codes have been added to this policy as medically necessary:

90912 and 90913

The following CPT code has been added as not covered:

90901

The following HCPCS code has been added as Not Covered in Home Setting per 04/01/2024 coding update:

S9002

The following CPT code has been removed because it is outside the scope of biofeedback therapy policy:

97112

Revisions From MA07.010a:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
03/08/2023	This policy was reviewed and reissued to communicate the Company's continuing position on Biofeedback Therapy.
06/29/2022	This policy was reviewed and reissued to communicate the Company's continuing position on Biofeedback Therapy.

10/06/2021	This policy was reviewed and reissued to communicate the Company's continuing position on Biofeedback Therapy.
11/18/2020	This policy has been reissued in accordance with the Company's annual review process.
09/25/2019	This policy has been reissued in accordance with the Company's annual review process.
06/20/2018	Effective 6/20/18, this policy has been reviewed and reissued to communicate the Company’s continuing position on Biofeedback Therapy.
10/06/2017	This version of the policy will become effective 10/06/2017. The policy has been reviewed and updated to communicate the Company’s continuing position on Biofeedback Therapy.

Revisions From MA07.010:

05/25/2016	This policy was reviewed and reissued to communicate the Company's continuing position on biofeedback therapy.
03/04/2015	The policy has been reviewed and reissued to communicate the Company’s continuing position on Biofeedback Therapy.
01/01/2015	This is a new policy.

Version Effective Date:

4/1/2024

Version Issued Date:

6/17/2024

Version Reissued Date: