Highmark Commercial Medical Policy - Pennsylvania

Printer Friendly Version

Medical Policy: Y-20-005
Topic: Biofeedback
Section: Therapy
Effective Date: May 14, 2018
Issue Date: May 14, 2018
Last Reviewed: March 2018

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

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

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 III 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 patients 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 [Canary Breathing System]) may be considered medically necessary as part of the overall treatment plan for adult individuals diagnosed with panic disorder when the individual is capable of participating in the treatment plan (physically and cognitively).

All other indications of biofeedback are considered experimental/investigational, and therefore, not covered.

Procedure Codes
90875, 90876, 90901, 90911, E0746

Functional Constipation Rome III Diagnostic Criteria

  • Must include two or more of the following:
    • Straining during at least 25% of defecations; or
    • Lumpy or hard stools in at least 25% of defecations; or
    • Sensation of incomplete evacuation for at least 25% of defecations; or
    • Sensation of anorectal obstruction/blockage for at least 25% of defecations; or
    • Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor); or
    • Fewer than three defecations per week; and
  • Loose stools are rarely present without the use of laxatives; and
  • Insufficient criteria for irritable bowel syndrome.

*Criteria fulfilled for the last three (3) months with symptom onset at least six (6) months prior to diagnosis.

Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Biofeedback is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

back to top