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| 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.
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.
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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.
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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.
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