Anorectal Biofeedback Printer-Friendly Version   

Medical Policy: 02.01.04 
Original Effective Date: July 2001 
Reviewed: July 2007 
Revised: January 2008 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description: 

Anorectal biofeedback is a treatment program that utilizes neuromuscular conditioning techniques to treat patients with fecal incontinence or chronic constipation that is associated with dyssynergic defecation.  Dyssynergic defecation, also known as anismus or pelvic floor dyssynergia, is characterized by failure of the abdominal, rectal, pelvic floor and anal sphincter muscles to coordinate and complete the act of defecation.  It is characterized by impaired propulsion of stool from the rectum, paradoxical anal contraction, or inadequate anal relaxation, or a combination of these mechanisms.

Appropriate candidates for receiving biofeedback therapy (neuromuscular training) are:

A. Patients who have a diagnosis of dyssynergic defecation.
B. Patients who have tried standard approaches for treatment of constipation including OTC laxatives, and failed these approaches for at least three months.
C. They should have fulfilled the symptomatic criteria for dyssynergic defecation.
D. They should have fulfilled the objective physiologic criteria for dyssynergic defecation described above.

Diagnostic criteria for dyssynegric defecation: Patients must fulfill both criteria A and criteria B as defined below.

A. Patients must fulfill the symptomatic criteria for functional constipation as defined by ROME III criteria, which states that patients must report two or more of the following symptoms for at least 3 months with a symptom onset of at least 6 months duration.

1. Straining during at least 25% defecations.
2. Lumpy or hard stools with at least 25% defecations.
3. Sensation of incomplete evacuation following at least 25% decations.
4. Sensation of anorectal obstruction or blockage during at least 25% defecations.
5. Manual maneuvers to facilitate bowel movements with at least 25% defecations (digital evacuation, etc.)
6. Fewer than three bowel movements per week.

B. Constipated patients must fulfill two or more of the following objective physiological criteria during repeated attempts to defecate.

1. Dyssnergic pattern of defecation that comprises of either inappropriate contraction of the pelvic floor muscles (anal sphincter of puborectalis) of less than 20% relaxation of basal resting sphincter pressure or
2. inadequate propulsive forces as assessed by manometry or imaging or EMG.
3. Inability to expel a 50 ml water-filled balloon or a stool-like device such as fecom within 1 minute.
4. A prolonged colonic transit time (more than 6 markers on a plain abdominal radiograph taken 120 hours after ingestion of one Stizmarks® capsule containing 24 radio opaque markers or using other technology such as nuclear scintigraphy or SmartPill® colonic transit study.)
5. Inability to expel barium paste or greater than 50% retention of barium past during defecography.

Anorectal biofeedback is an instrument-based learning technique wherein an instrument such as a manometry probe is placed inside the body to provide visual or auditory information to the patient regarding their anorectal muscle function.

Biofeedback therapy is a process based on operant conditioning techniques and the governing principle is that any behavior – whether complex or simple – is reinforced. It can be performed either by placing a manometry probe with multiple micro-transducers and a balloon or a water perfused probe with multiple side holes into the rectum. This in turn provides either visual or auditory display of muscle activity.  The patient and the therapist use this information to learn how to control and improve anorectal function.  In addition to office biofeedback training, portable units are also available to facilitate home training.

The treatment consists of advice and instruction during an initial visit regarding bowel habits, exercise, laxatives, dietary fiber and fluid intake and timed toilet training.  In addition to receiving the instruction, subjects have an initial training session by a specialist generally followed by biweekly, 1-hour biofeedback sessions, up to a maximum of 6 therapy sessions during a period of 3 months during the active phase.  A follow up phase typically consists of reinforcement at 6 weeks and 3, 6, and 12 months.

Policy: 

Anorectal biofeedback may be considered medically necessary for documented dyssynergic defecation.

Anorectal biofeedback is considered investigational for any condition not listed above.

Top

Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• CPT code 90911; biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG or manometry.

Top

Selected References: 

• Ko, C.Y., Tong, J., Lehman, R.E., Selton, A.A., Schrock, T.R., Welton, M.L. Biofeedback is effective therapy for fecal incontinence and constipation. Archives of Surgery 1997; 132: 829-834. 
• Chiotakakou-Faliakou, E., Kamm, M.A., Roy, A.J., Storrie, J.B., Turner, I.C. Biofeedback provides long term benefit for patients with intractable, slow and normal transit constipation. Gut 1998; 42: 517-521.
• McKee, R.F., McEnroe, L., Anderson, J.H., Finlay, I.G. Identification of patients likely to benefit from biofeedback for outlet obstruction constipation. British Journal of Surgery 1999; 86: 355-359. 
• Gilliland, R., Hyemen, S., Altomare, D.F., Park, U.C., Vickers, D., Wexner, S.D. Outcome and predictors of success of biofeedback for constipation. British Journal of Surgery 1997; 84: 1123-1126.
• Rao, S.S.C. The technical aspects of biofeedback therapy for defecation disorder. The Gastroenterologist 1998; 6:96-103.
• ECRI. Biofeedback for the Treatment of Constipation in Children.  Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service; 1998 October 19 p. (Windows on medical technology; Issue No. 10).
• ECRI. Biofeedback for the Treatment of Fecal Incontinence. Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service; 1998 October 18 p. (Windows on medical technology; Issue No. 11). 
• Dailianas, A., Skandlis, N., Rimikis, M.N., Koutsomanis, D., Kardasi, M., Archimandritis, A. Pelvic floor study in patients with obstructive defecation. Journal of Clinical Gastroenterology 2000; 30(2):176-180.
• McKee, R.F., McEnroe, L., Anderson, J.H., Finlay, I.G. Identification of patients likely to benefit from biofeedback for outlet obstruction constipation. British Journal of Surgery 1999;86:355-359.
• AHRQ 01-E030. Mind-Body Interventions, Gastrointestinal Conditions. Evidence Report/ Technology Assessment No. 40. Evidence Report. July 2001. 
• Solomon MJ, Pager CK, Rex J, Roberts R, Manning J. Randomized, controlled trial of biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital guidance alone in the treatment of mild to moderate fecal incontinence.  Dis Colon Rectum.  2003 Jun;46(6):703-10.
• Norton C, Chelvanayagam S, Wilson-Barnett J, Redfern S, Kamm MA   Randomized controlled trial of biofeedback for fecal incontinence.  Gastroenterology.  2003 Nov;125(5):1320-9.
• Ilnyckyj A, Fachnie E, Tougas G.  A randomized-controlled trial comparing an educational intervention alone vs education and biofeedback in the management of faecal incontinence in women.  Neurogastroenterol Motil. 2005 Feb;17(1):58-63.
• Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev 2006 19; (2):CD002240. Abstract viewed on-line.
• Rao SS, Seaton K, et al.  Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation.  Clin Gastroenterol Hepatol. 2007 Mar;5(3):331-8. 

Top

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.