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Biofeedback

Section: Therapy
Effective Date: January 01, 2020
Revised Date: December 17, 2019
Last Reviewed: September 26, 2019

Description

Biofeedback, a technique intended to teach individuals self-regulation of certain physiologic processes not normally considered to be under voluntary control.

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% 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.

Failure is defined as no clinically significant improvement in urinary continence after completing four (4) weeks of an ordered regimen of PMEs.

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).

All other indications of biofeedback are considered experimental/investigational due lack of scientific evidence, and therefore, not covered. Safety and efficacy cannot be established by review of the available published peer-reviewed literature.

Procedure Codes

90875 90876 90901 90912 90913 A9279 E0746

Diagnosis Codes

F40.01 F41.0 G43.001 G43.009 G43.011 G43.019 G43.101
G43.109 G43.111 G43.119 G43.401 G43.409 G43.411 G43.419
G43.501 G43.509 G43.511 G43.519 G43.701 G43.709 G43.711
G43.719 G43.801 G43.809 G43.811 G43.819 G43.901 G43.909
G43.911 G43.919 G44.201 G44.209 G44.211 G44.219 G44.221
G44.229 K59.00 K59.01 K59.02 K59.03 K59.04 K59.09
N39.3 N39.41 N39.46 N39.491 N39.492 R15.0 R15.1
R15.2 R15.9 R32