Criteria
Biofeedback for constipation in adults may be considered medically necessary for individuals with dyssynergia-type constipation as demonstrated by meeting
ALL
of the following criteria:
-
Symptoms of functional constipation that meet ROME IV criteria;
and
-
Objective physiologic evidence of pelvic floor dyssynergia demonstrated by inappropriate contraction of the pelvic floor muscles or less than 20 percent relaxation of basal resting sphincter pressure by manometry, imaging or electromyography (EMG);
and
- Failed a three (3) month trial of standard treatments for constipation including laxatives, dietary changes, and exercises (as many of the previous as are tolerated).
Biofeedback may be considered medically necessary as part of the overall treatment plan for migraine and tension-type headache. Before a biofeedback program is introduced, a physician must determine that the headaches are not pathological in nature. Such pathologies include:
-
Brain tumors;
or
-
Hematoma;
or
-
Edema;
or
-
Aneurysm;
or
- Disease of the eyes, ears, or sinus.
Biofeedback may be considered medically necessary for the treatment of stress and/or urge incontinence in cognitively intact individuals who have failed a documented trial of pelvic muscle exercise (PME) training. A failed trial is defined as no clinically significant improvement in urinary continence after completing four (4) weeks of an ordered regimen of PMEs.
Intra-vaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device may be considered medically necessary for the non-surgical/non-pharmacological treatment of UI:
-
Bladder retraining;
or
-
Habit training or timed voiding;
or
-
PME/Kegel which may be augmented by the use of biofeedback, electrical stimulation of the pelvic floor, or the use of vaginal weights;
or
- Myofacial release and pelvic floor relaxation exercise.
Urinary continence therapy not meeting the criteria as indicated in this policy is considered not medically necessary.
Biofeedback using capnometry guided respiratory intervention (CGRI) (e.g., Freespira may be considered medically necessary as part of the overall treatment plan for adult individuals, age 18 and older, diagnosed with panic disorder and/or posttraumatic stress disorder (PTSD) when the individual is capable of participating in the treatment plan (physically and cognitively).
Biofeedback, not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, not covered because the safety and efficacy cannot be established by review of the available published peer-reviewed literature.
Procedure Codes
| 90875 | 90876 | 90901 | 90912 | 90913 | A9279 | E0746 |
| S9002 |
