Medical Policy: 02.01.05
Original Effective Date: October 2002
Reviewed: July 2016
Revised: July 2016
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not normally considered to be under voluntary control. It is frequently used in conjunction with other therapies (i.e., relaxation, behavioral management, medication) to reduce the severity and/or frequency of headaches and as a treatment for a variety of diseases and disorders including anxiety, hypertension, movement disorders, incontinence, pain, and asthma. Professionals who use this technique assume that patients who achieve greater biofeedback control over the relevant physiological functions will be more successful in reducing their symptoms.
Biofeedback involves the feedback of a variety of types of information not normally available to the patient, followed by a concerted effort on the part of the patient to use this feedback to help alter the physiological process in some specific way. Biofeedback training is done either in individual or group sessions, alone or in combination with other behavioral therapies designed to teach relaxation. A typical course of treatment consists of 10 to 20 training sessions of 30 to 60 minutes each. Training sessions are conducted in a quiet, non-rousing environment. Subjects are instructed to use mental techniques to affect the physiologic variable monitored, and feedback is provided for successful alteration of the physiologic parameter. This feedback may be signals such as lights or tone, verbal praise, or other auditory or visual stimuli.
The various forms of biofeedback differ mainly in the nature of the disease or disorder under treatment, the biologic variable that the individual attempts to control, and the information that is fed back to the individual. Biofeedback techniques include peripheral skin temperature feedback, blood-volume-pulse feedback (vasoconstriction and dilation), vasoconstriction training (temporalis artery), and electromyographic (EMG) biofeedback; these may be used alone or in conjunction with other therapies. Generally, EMG biofeedback is used to treat tension headaches, and thermal biofeedback is used to treat migraine headaches. In EMG biofeedback, electrodes are attached to the temporal muscles. The degree of muscle tension is fed back to the individual being treated and the subject is asked to reduce muscle tension. For thermal biofeedback, a temperature sensor is placed on the finger, and the subject is taught to increase the temperature, an effect that is mediated through peripheral vasodilation. According to the National Center for Complementary and Alternative Medicine (NCCAM), biofeedback is considered an alternative medicine technique.
A variety of biofeedback devices are cleared for marketing through the U.S. Food and Drug Administration (FDA) 510(k) process. These devices are designated by the FDA as class II with special controls and are exempt from the premarket notification requirements. The FDA defines a biofeedback device as "an instrument that provides a visual or auditory signal corresponding to the status of one or more of a patient's physiological parameters (e.g., brain alpha wave activity, muscle activity, skin temperature, etc.) so that the patient can control voluntarily these physiological parameters."
Another form of biofeedback is electroencephalogram (EEG) biofeedback, also called neurofeedback, brainwave biofeedback or neurotherapy, which measures alpha (associated with relaxation and meditation) and theta (associated with focused attention) brainwave activity. It is proposed to counterbalance genetic and environmental tendencies by learning to alter brain wave patterns. Neurofeedback describes techniques of providing feedback about neuronal activity, as measured by electroencephalogram (EEG) biofeedback or functional magnetic resonance imaging (fMRI), in order to teach patients to self-regulate brain activity. Neurofeedback may utilize several techniques in an attempt to normalize unusual patterns of brain function in patients with central nervous system (CNS) disorders, such as attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder, substance abuse, epilepsy, and insomnia.
The American Academy of Family Physicians’ 2000 guidelines on preventive therapy for migraines, based on evidence review by the U.S. Headache Consortium, recommend relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive-behavioral therapy as treatment options for prevention of migraine (Grade A recommendation). Relaxation techniques and biofeedback may be combined with preventative drug therapy to achieve additional clinical improvement (Grade B recommendation). According to the guidelines, nonpharmacologic therapy may be well-suited for patients who have exhibited a poor tolerance or poor response to drug therapy, who have a medical contraindication to drug therapy, and who have a history of long-term, frequent or excessive use of analgesics or other acute medications. Nonpharmacologic intervention may also be useful in patients with significant stress or in patients who are pregnant, are planning to become pregnant, or are nursing.
The American Academy of Neurology’s recommendations for the evaluation and treatment of migraine headaches states that behavioral and physical interventions are used for preventing migraine episodes rather than for alleviating symptoms once an attack has begun. Although these modalities may be effective as monotherapy, they are more commonly used in conjunction with pharmacologic management. Relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy may be considered treatment options for prevention of migraine. Specific recommendations regarding which of these to use for specific patients cannot be made.
In 2010, the European Federation of Neurological Societies gave an A-level recommendation for use of EMG biofeedback for the treatment of tension-type headache, based on the meta-analysis by Nestoriuc et al. The guidelines state that the aim of EMG biofeedback is to help the patient to recognize and control muscle tension by providing continuous feedback about muscle activity. Sessions typically include an adaptation phase, baseline phase, training phase, during which feedback is provided, and a self-control phase, during which the patient practices controlling muscle tension without the aid of feedback.
American Academy of Neurology (AAN) and the American Clinical Neurophysiology Society (ACNS)
A report from The AAN and the ACNS on the assessment of digital EEG, quantitative EEG, and EEG brain mapping was reaffirmed in 2013. The report states that:
“On the basis of current clinical literature, opinions of most experts, and proposed rationales for their use, QEEG remains investigational for clinical use in postconcussion syndrome, mild or moderate head injury, learning disability, attention disorders, schizophrenia, depression, alcoholism, and drug abuse.”
In reference to the management of cancer pain, the National Cancer Institute (NCI) (2014) states that alternative therapies (e.g., biofeedback) may be used in conjunction with pain medication in an effort to control pain. NCI stated that even though non-medical therapies have not been tested in cancer pain studies, they may help to relieve pain, stress and anxiety therefore, improving the patient’s quality of life.
Biofeedback may be considered medically necessary as part of the overall treatment plan for migraine and tension-type headache.
Biofeedback for the treatment of cluster headache is considered investigational.
Biofeedback may be considered medically necessary as part of the overall treatment for cancer pain.
Unsupervised home use of biofeedback is considered not medically necessary. Home use of biofeedback equipment is not medically necessary.
Neurofeedback is considered investigational. Neurofeedback, and EMG controlled neuromuscular electrical stimulation (e.g., the Care EMG), are considered investigational, as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure.
Biofeedback/Neurofeedback is considered investigational for all indications not listed above including, but not limited to:
- Anxiety disorders
- Sleep bruxism
- Movement disorders
- Bell's palsy
- Motor function after stroke, injury, or lower-limb surgery
- Raynaud's disease or phenomenon
- Orthostatic hypotension in patients with spinal cord injury
- Pain management during labor
- Chronic Pain including cancer pain
- Attention deficit disorder
- Fecal and urinary incontinence
- Irritable bowel syndrome
- Anorectal pain syndrome
- Anger Management
- Multiple Sclerosis
There continues to be insufficient evidence to demonstrate the effectiveness of biofeedback for the miscellaneous conditions listed above. Studies either fail to demonstrate any beneficial impact of biofeedback or have design flaws that leave the durability of effects in question or create uncertainty about the contribution of nonspecific factors such as attention or placebo effects.
For neurofeedback the evidence is poor in showing effect on health outcomes and a number of questions regarding clinical efficacy remain to be answered.
Most of the published randomized controlled trials (RCTs) on biofeedback from chronic pain have not found a significantly greater benefit when biofeedback is offered instead of or in addition to other conservative interventions.
Devices used in biofeedback therapy (eg, electromyography [EMG], biofeedback device) are not eligible for separate reimbursement because they are inherent to the biofeedback service.
See the related policy number 02.01.04 Anorectal Biofeedback
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes
- 90901 Biofeedback training by any modality
- 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately 20-30 minutes
- 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately 45-50 minutes
- E0746 Electromyography (EMG), biofeedback device
- Sarafino EP, Goehring BA. Age comparisons in acquiring biofeedback control an success in reducing headache pain. Annals of Behavioral Medicine 2000; 22(1):10-16.
- Bussone G, Grazzi L, D'Amico D, Leone M, Andrasik F. Biofeedback-assisted relaxation training for young adolescents with tension-type headache: a controlled study. Cephalalgia 1998; 18: 463-467.
- Mauskop A. Alternative Therapies in Headache. Is there a role? Headache 2001; 85(4):1077-1084.
- Silberstein SD, Rosenberg J. Multispecialty consensus on diagnosis and treatment of headache. Neurology 2000;54:1553.
- Yucha CB. Problems inherent in assessing biofeedback efficacy studies. Appl psychophysiol Biofeedback. 2002 Mar; 27(1): 99-106.
- Nakao M, Yano E, Nomura S et al. Blood pressure-lowering effects of biofeedback treatment in hypertension: a meta-analysis of randomized controlled trials. Hypertens Res 2003; 26(1):37-46.
- Sierpina V, Astin J, Giordano J. Mind-Body Therapies for Headache. Am Fam Physician 2007;76:1518-1522.
- National Institute of Neurological Disorders and Stroke (NINDS). Headache Information PageExternal Site.
- Silkman C, McKeon J. The effectiveness of electromyographic biofeedback supplementation during knee rehabilitation after injury. J Sports Rehabil 2010; 19(3):343-51.
- Coben R, Myers TE. The relative efficacy of connectivity-guided and symptom-based EEG biofeedback for autistic disorders. Appl Psychophysiol Biofeedback 2010; 35(1):13-23.
- Mann JD, Coeytaux RR. Migraone and tension-type headache. In: Rakel D, ed. Integrative Medicine, 2nd edition. Philadelphia: Saunders Elsevier, 2007.
- Gerber WD, Petermann F, Gerber-von Muller G et al. MIPAS_Family-evaluation of a new multi-modal behavioral training program for pediatric headaches: clinical effects and the impact on quality of life. J Headache Pain 2010; 11(3): 215-25.
- Bendtsen L, Evers S, Linde M et al. EFNS guideline on the treatment of tensio-type headache-report of an EFNS task force. Eur J Neurol 2010; 17(11):1318-25.
- Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain 2007; 128(1-2):111-27.
- Nestoriuc Y, Rief W, Martin A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J Consult Clin Psychol 2008; 76(3):279-96.
- Macfarlane GJ, Paudyal P, Doherty M, et al. A systematic review of evidence for the effectiveness of practitioner- based complementary and alternative therapies in the management of rheumatic diseases: osteoarthritis. Rheumatology (Oxford). 2012 Dec;51(12):2224-2233.
- Jones L, Othman M, Dowswell T, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012 Mar 14;3:CD009234.
- Collins NJ, Bisset LM, Crossley KM, Vicenzino B. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Sports Med. 2012 Jan 1;42(1):31-49.
- Sporbeck B, Mathiske-Schmidt K, Jahr S, Huscher D, et al. Effect of biofeedback and deep oscillation on Raynaud's phenomenon secondary to systemic sclerosis: results of a controlled prospective randomized clinical trial. Rheumatol Int. 2012 May;32(5):1469-73.
- ECRI Institute. [Evidence Reports] Neurofeedback for treatment of attention deficit hyperactivity disorder. 2/2/2007.
- National Institute of Neurologic Disorders and Stroke. NINDS Headache Information PageExternal Site.
- Diagnosis and treatment of headache. Executive summary. Bloomington (MN): Institute for Clinical Systems Improvement; 2013 Jan. 2 p.
- American Academy of Family Practice. Guidelines on migraine: part 4. General principles of preventive therapyExternal Site. Am Fam Physician 2000.
- Bendtsen L, Evers S, Linde M et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol 2010; 17(11):1318-25.
- National Coverage Determination (NCD) for Biofeedback Therapy (30.1)External Site.
- American Cancer Society. Pain Control: A guide for those with cancer and their loved ones. Jun 10, 2014.
- Mackay AM, Buckingham R, Schwartz RS, et al. The Effect of Biofeedback as a Psychological Intervention in Multiple Sclerosis: A Randomized Controlled Study. Int J MS Care. May-Jun 2015;17(3):101-108. PMID 26052255
- Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Institute for Clinical Systems Improvement. Assessment and Management of Chronic Pain. Updated November 2013.
- Neurofeedback and Biofeedback for Mood and Anxiety Disorders: A Review of the Clinical Evidence and Guidelines - An Update. Ottawa ON: 2014 Canadian Agency for Drugs and Technologies in Health; 2014.
- American Cancer Society. Pain Control: A Non-medical treatments for pain. Sept 23, 2015. Accessed Nov 2, 2015. Available at URL address: http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/pain/non-medical-treatments-for-cancer-pain
- American College of Obstetricians and Gynecologists (ACOG). Committee on Gynecologic Practice. ACOG Committee Opinion: Number 345: vulvodynia. Oct 2006. Reaffirmed 2015. Available at URL address: http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/Vulvodynia
- National Institute for Health and Clinical Excellence (NICE). Clinical guideline 137. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. Feb 2014. Available at URL address: http://guidance.nice.org.uk/CG137
- Association for Applied Psychphysiology and Biofeedback I. Standards for Performing Biofeedback. 2013; http://www.aapb.org/i4a/pages/index.cfm?pageid=3678#II. Accessed March, 2015.
July 2016 - Annual Review, Policy Revised
August 2015 - Annual Review, Policy Revised
Septemeber 2014 - Annual Review, Policy Revised
Ocotber 2013 - Annual Review, Policy Renewed
December 2012 - Annual Review, Policy Renewed
December 2011 - Annual Review, Policy Renewed
December 2010 - Annual Review, Policy Renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
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and, therefore, cannot guarantee any results or outcomes.
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.