Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Biofeedback coverage depends on your specific insurance plan. Consult your plan benefit document or contact QualChoice customer service department.

1)    When biofeedback is a covered service, it can be used for the following conditions (PA required beyond 10 sessions to ensure benefit & review treatment plan):

a)    Urinary incontinence; female;

b)    Fecal incontinence;

c)    Levator ani syndrome.

2)    When biofeedback is a covered service, it can be used for the following conditions:

a)    Tension headaches (muscle, thermal or skin biofeedback only; EEG biofeedback is considered experimental and investigational for this indication);

b)    Temporomandibular joint (TMJ) syndrome (when the member is covered by a TMJ rider);

c)    Neuromuscular rehabilitation of stroke and traumatic brain injury (TBI) (see note below);

d)    Raynaud`s disease;

e)    Irritable bowel syndrome;

f)     Refractory severe subjective tinnitus;

g)    Migraine headaches when chemoprophylaxis has been ineffective.

3)    For biofeedback with psychotherapy see BI273.

4)    Note: AutoMove AM800 is not covered. It is not biofeedback and has not been shown to be effective in treating post stroke patients.

Codes Used In This BI:

1)    The use of biofeedback is not eligible for benefits for temporomandibular joint disorders unless the benefit contract has a TMJ rider.

2)    Biofeedback is not covered for the following conditions (not an exhaustive list):

a)    Ordinary muscle tension states, psychosomatic conditions, visual disorders;

b)    Essential hypertension (e.g., by means of the RESPeRATE Device);

c)    Anterior shoulder instability or pain;

d)    Attention deficit hyperactivity disorder ;

e)    Anxiety disorders;

f)     Chronic pain (e.g., fibromyalgia, back pain, neck pain) other than migraine and tension headache;

g)    Epilepsy;

h)    As a rehabilitation modality for spinal cord injury, spasmodic torticollis, or following knee surgeries;

i)     Spasticity secondary to cerebral palsy;

j)     Addictions;

k)    Depression;

l)     Insomnia;

m)  Allergy;

n)    Autism;

o)    Chronic fatigue syndrome;

p)    Daytime syndrome of urinary frequency;

q)    Vertigo/disequilibrium;

r)     Urinary retention;

s)    Labor pain;

t)     Tourette’s syndrome;

u)    Type 2 diabetes;

v)    Chronic prostatitis;

w)   Tremors;

x)    Vaginismus;

y)    Peripheral arterial disease (e.g., intermittent claudication);

z)    Facial pain;

aa) Functional dysphonia.

3)    Treatment beyond Ten (10) sessions will require PA with treatment plan and documentation of significant benefit from the treatments.

Addendum:

Effective 7/1/2018: Modified biofeedback PA requirement – no PA for specific conditions (when covered) but PA needed beyond 10 sessions.

Effective 01/01/2020: Code updates – Added new codes 90912 and 90913 to search box and claims statement as well as added the descriptions eff 01/01/2020.  Deleted code 90911 eff 01/01/2020.