Biofeedback and Neurofeedback
Biofeedback policy statements do not apply to Medicare Advantage.
DESCRIPTION
Biofeedback is a technique used to train an individual in self-regulation of a physiological processes not generally considered to be under voluntary control. Various measuring, recording instruments and monitors may be used in the training. Biofeedback training is done in individual sessions, group sessions, alone or with other behavioral therapies designed to teach relaxation. Biofeedback has been proposed as a treatment for a variety of conditions including anxiety, headache, urinary and fecal incontinence, constipation, pain, and temporomandibular joint dysfunction.
Neurofeedback describes techniques of providing feedback about neuronal activity, as measured by electroencephalogram (EEG), functional magnetic resonance imaging or near-infrared spectroscopy, to teach individuals to self-regulate brain activity. Neurofeedback differs from traditional forms of biofeedback in that the information fed back to the individual is a direct measure of global neuronal activity, or brain state. Purportedly, the individual may be trained to either increase or decrease the prevalence, amplitude, or frequency of specified EEG waveforms, depending on the changes in brain function associated with the particular disorder. Neurofeedback is being explored for the treatment of a variety of disorders including attention deficit/hyperactivity disorder, Tourette syndrome, autism spectrum disorder, traumatic brain injury, seizure disorders, anxiety disorders, fibromyalgia, tinnitus, substance abuse disorders, depression, and as a stress management technique.
POLICY
Biofeedback training or therapy is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below).
Biofeedback for the treatment of all other conditions/diseases is considered investigational.
Neurofeedback for the treatment of all conditions/diseases is considered investigational.
MEDICAL APPROPRIATENESS
Biofeedback may be indicated for ANY ONE of the following:
Migraine or tension-type headache if ALL the following criteria are met:
Pharmacologic treatment is inadequate or not indicated, by reason of 1 or more of the following:
Individual is pregnant
Individual is attempting to become pregnant
Individual is breast-feeding
Insufficient or no response to multiple pharmacologic treatment attempts
Intolerance of multiple pharmacologic treatment attempts
History of long-term, frequent or excessive use of analgesic or medications
ABSENCE of ALL the following:
Cluster headache
Unsupervised home use of biofeedback
No more than 20 sessions of biofeedback per twelve months
Constipation if ALL the following criteria are met:
Failure of 3 months standard treatment, e.g., laxatives, dietary changes, exercise (as tolerated)
Documentation of pelvic floor dyssynergia as indicated by ANY ONE of the following:
Inappropriate contraction of the pelvic floor muscles
Less than 20% relaxation of basal resting sphincter pressure
Insufficient criteria for irritable bowel syndrome
Up to 6 biofeedback sessions over 3 months
Urinary incontinence if ALL of the following criteria are met:
Documentation of stress, urge, mixed, overflow, or persistent post-prostatectomy incontinence
Cognitively intact
Failure of conservative treatment (e.g., medication, bladder training, pelvic muscle training)
No clinically significant improvement in urinary incontinence after completing 4 weeks of pelvic muscle training
Fecal incontinence if ALL of the following criteria are met:
Ability to voluntarily contract the sphincter
The individual has some degree of rectal sensation
Failure of conservative treatment (e.g., medication, diet changes, bowel training, pelvic muscle training)
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
Biofeedback policy statements do not apply to Medicare Advantage.
ADDITIONAL INFORMATION
There is a lack of scientific evidence to determine the effect of health outcomes or clinical efficacy for all conditions not listed as medically appropriate above.
SOURCES
Alouini, S., Memic, S., & Couillandre, A. (2022). Pelvic floor muscle training for urinary incontinence with or without biofeedback or electrostimulation in women: A systematic review. International Journal of Environmental Research and Public Health, 19 (5), 2789. (Level 1 evidence)
American Academy of Family Physicians. (2000). Guidelines on migraine: part 4. General principles of preventive therapy. Retrieved September 18, 2018 from https://www.aafp.org/afp/2000/1115/p2359.html.
American Academy of Pediatrics. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Retrieved April 16, 2021 from http://pediatrics.aappublications.org.
American College of Gastroenterology. (2021, October). ACG clinical guidelines: management of benign anorectal disorders. Retrieved June 9, 2023 from https://www.gi.org/guidelines/.
American College of Obstetrics and Gynecology. (2015; reaffirmed 2018). ACOG practice bulletin #155: urinary incontinence in women. Retrieved May 31, 2023 from www.acog.org.
American College of Physicians. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Retrieved September 18, 2018 from https://www.acponline.org/clinical-information/guidelines.
American Gastroenterological Association. (2013). American Gastroenterological Association medical position statement on constipation. Retrieved September 18, 2018 from http://www.gastrojournal.org.
American Society of Colon and Rectal Surgeons. (2023). Clinical practice guidelines for the management of fecal incontinence. Retrieved July 6, 2023 from https://www.fascrs.org/ascrs/media/files/2023-fecakl-incontinence-cpg.pdf.
American Urological Association (AUA) / Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). (2019). Incontinence after prostate treatment: AUA/SUFU guideline. Retrieved June 1, 2023 from https://www.auanet.org.
American Urological Association (AUA) / Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). (2023). Updates to surgical treatment of female stress urinary incontinence (sui): AUA/SUFU guideline (2023). Retrieved June 1, 2023 from https://www.auanet.org.
BlueCross BlueShield Association. Evidence Positioning System. (12:2023). Biofeedback as a treatment of chronic pain (2.01.30). Retrieved August 27, 2024 from https://www.bcbsaoca.com/eps/. (53 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (12:2023). Biofeedback as a treatment of headache (2.01.29). Retrieved August 27, 2024 from https://www.bcbsaoca.com/eps/. (9 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (12:2023). Biofeedback for miscellaneous indications (2.01.53). Retrieved August 27, 2024 from https://www.bcbsaoca.com/eps/. (43 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (12:2023). Biofeedback as a treatment of fecal incontinence or constipation (2.01.64). Retrieved August 27, 2024 from https://www.bcbsaoca.com/eps/. (22 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (3:2024). Temporomandiubular Joint Disorder (2.01.21). Retrieved August 27, 2024 from https://www.bcbsaoca.com/eps/. (46 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (3:2024). Treatment of Tinnitus (8.01.39). Retrieved August 27, 2024 from https://www.bcbsaoca.com/eps/. (47 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (9:2023). Biofeedback as a treatment of urinary incontinence in adults (2.01.27). Retrieved September 6, 2023 from https://www.bcbsaoca.com/eps/. (31 articles and/or guidelines reviewed)
Centers for Medicare & Medicaid Services. CMS.gov. NCD for biofeedback therapy (30.1). Retrieved December 7, 2015 from http://www.cms.gov.
Centers for Medicare & Medicaid Services. CMS.gov. NCD for biofeedback therapy for the treatment of urinary incontinence (30.1.1). Retrieved December 4, 2015 from http://www.cms.gov.
Hsu, L., Liao, Y., Lai, F., & Tsai, P. (2016). Beneficial effects of biofeedback-assisted pelvic floor muscle training in patients with urinary incontinence after radical prostatectomy: A systematic review and metaanalysis. International Journal of Nursing Studies, 60, 99–111. Abstract retrieved June 1, 2023 from PubMed database.
Leonardo, K., Seno, D., Mirza, H., & Afriansyah, A. (2022). Biofeedback-assisted pelvic floor muscle training and pelvic electrical stimulation in women with overactive bladder: A systematic review and meta-analysis of randomized controlled trials. Neurourology and Urodynamics, 41 (6), 1258–1269. Abstract retrieved May 31, 2023 from PubMed database.
Li, H., Guo, C., Gao, J., & Yao, H. (2022). Effectiveness of biofeedback therapy in patients with bowel dysfunction following rectal cancer surgery: a systemic review with meta-analysis. Therapeutics and Clinical Risk Management, 18, 71–93. (Level 1 evidence)
National Institute for Health and Care Excellence. (2007, June; last updated July 2018). Clinical guidance: Faecal incontinence in adults: management. Retrieved April 16, 2021 from www.nice.org/uk.
National Institute for Health and Care Excellence. (2010, May; last updated July 2017). Clinical guidance: Constipation in children and young people: diagnosis and management. Retrieved October 11, 2017 from www.nice.org/uk.
National Institute for Health and Care Excellence. (2019, April; last updated June 2019). Urinary incontinence and pelvic organ prolapse in women: management. Retrieved July 3, 2023 from www.nice.org/uk.
Ussing, A., Dahn, I., Due, U., Sørensen, M., Petersen, J., & Bandholm, T. (2019). Efficacy of supervised pelvic floor muscle training and biofeedback vs attention-control treatment in adults with fecal incontinence. Clinical Gastroenterology and Hepatology, 17 (11), 2253–2261. (Level 2 evidence)
Wu, X., Zheng, X., Yi, X., Lai, P., & Lan, Y. (2021). Electromyographic biofeedback for stress urinary incontinence or pelvic floor dysfunction in women: a systematic review and meta-analysis. Advances in Therapy, 38 (8), 4163-4177. (Level 2 evidence)
ORIGINAL EFFECTIVE DATE: 4/1980
MOST RECENT REVIEW DATE: 10/10/2024
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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