Clinical Policy: Biofeedback Form

CENTENE®
Corporation

Clinical Policy: Biofeedback
Reference Number: CP.MP.168
Date of Last Revision: 11/24

Coding Implications
Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description
Biofeedback therapy provides visual, auditory or other evidence of the status of certain body functions so that a person can exert voluntary control over the functions, and thereby alleviate an abnormal bodily condition. Biofeedback therapy often uses electrical devices to transform bodily signals indicative of such functions as heart rate, blood pressure, skin temperature, salivation, peripheral vasomotor activity, and gross muscle tone into a tone or light, the loudness or brightness of which shows the extent of activity in the function being measured.¹

Note: For neurofeedback for behavioral health conditions, refer to CP.BH.300 Neurofeedback for Behavioral Health Conditions.

Policy/Criteria
I. It is the policy of health plans affiliated with Centene Corporation® that biofeedback is medically necessary when all of the following are met:
A. Member/enrollee is cognitively and physically capable of participating in the agreed upon plan of care and motivated to actively participate in the treatment plan requirements (e.g., practice and follow-through at home);

Note: If member/enrollee is a child, support and guidance are available for fulfillment of the plan of care (e.g., practice and follow-through at home);

B. One of the following:

1. Urinary incontinence (i.e., stress, urge, or mixed) in adult members/enrollees who have failed a documented four week trial of pelvic muscle exercise training;  
2. Dysfunctional voiding in children when other alternative options have been unsuccessful (e.g., timed voiding, prophylactic antibacterial therapy for recurrent urinary tract infections, short term anticholinergic medications to assist developing a normal voiding pattern);  
3. Fecal incontinence and all of the following:  
    a. One of the following:  
        i. Anorectal manometry demonstrates weakness of the external anal sphincter;  
        ii. Decreased ability to perceive rectal distension because of nerve injury;  
    b. None of the following contraindications:  
        i. Isolated internal anal sphincter weakness;  
        ii. Overflow incontinence associated with behavioral or psychiatric disorders;  
        iii. Neurological disorders associated with substantial loss of rectal sensation and/or the inability to contract the external anal sphincter;  
        iv. Decreased rectal storage capacity from resection, inflammation, or fibrosis;  
        v. Suspected or established major structural damage to continence mechanisms;  
4. Chronic constipation;  
5. Tension or migraine headaches;  
6. Chronic pain;

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CLINICAL POLICY
Biofeedback

7. Muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm (including pain due to spasm), or weakness.

II. It is the policy of health plans affiliated with Centene Corporation that there is insufficient evidence to support the safety and efficacy of biofeedback for any other conditions than those specified above.

Background
The three most commonly used forms of biofeedback therapy are: (1) electromyography (EMG), which measures muscle tension; (2) thermal biofeedback, which measures skin temperature; and (3) neurofeedback or electroencephalography (EEG), which measures brain wave activity. Various forms of biofeedback appear to be effective for a narrow range of health problems. Biofeedback training is performed by a physician or qualified non-physician practitioner, which can include physical and occupational therapists, nurse practitioners, physician assistants, and clinical nurse specialists.²

First line treatment of urinary incontinence (i.e., stress, urgency, mixed) consists of behavioral treatments with an emphasis on improving quality of life. Initial treatment includes lifestyle modifications and pelvic floor muscle exercise. Biofeedback is used as an adjunct to pelvic floor muscle exercises. By providing individuals with concurrent feedback on muscle tone, biofeedback is intended to improve the patient’s ability to perform pelvic floor exercises. Augmented versions also use abdominal and perineal EMG recordings to demonstrate improper contraction of abdominal and gluteal muscles. A systematic review and meta-analysis of 17 randomized or quasi-randomized trials found that compared with women who received pelvic floor muscle exercises alone, those that also received biofeedback were more likely to report improvement or cure of urinary incontinence.¹

Dysfunctional voiding in children is a learned behavior of abnormal urination, which often evolves from attempts to suppress impending or active bladder contractions by inappropriately contracting the pelvic floor muscles, thereby tightening the urinary sphincter complex. Symptoms vary, but daytime wetness and urinary tract infections are common.³ Other urinary symptoms include urgency, frequency, infrequency, and constipation. Usual care of dysfunctional voiding includes voiding on a schedule and keeping voiding diaries. Pelvic floor exercises may help children gain conscious control of pelvic floor musculature and urination.⁴ Biofeedback teaches children how to identify and control the muscle groups involved in voiding. It is reserved for children with dysfunctional voiding despite an adequate trial of conservative therapy and/or pharmacotherapy. Available studies suggest that biofeedback-directed pelvic floor exercises can improve urinary function in dysfunctional voiding, including those who have previously failed conservative treatment. Biofeedback therapy may result in a faster resolution of symptoms than traditional pelvic floor training without biofeedback.³

Biofeedback therapy improves symptoms in more than 70% of patients with defecatory disorders. Biofeedback can be useful in the treatment of constipation to train patients to relax their pelvic floor muscles during straining and to correlate relaxation and pushing to achieve defecation. By the relearning process, the non-relaxing pelvic floor is gradually suppressed and

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Biofeedback

normal coordination restored. Biofeedback has been shown to improve rectoanal coordination during defecation and symptoms of constipation despite reduced laxative use. Biofeedback is also used in the treatment of fecal incontinence.⁵

American Gastroenterological Association (AGA)
The AGA states that pelvic floor retraining by biofeedback therapy rather than laxatives is recommended for defecatory disorders (strong recommendation, high-quality evidence).⁴ Instrumented anorectal biofeedback therapy should be used to manage symptoms in defecatory disorders (strong recommendation; minimal risk of harm; quality of evidence: moderate).⁶

American Society of Colon and Rectal Surgeons (ASCRS)
The 2023 updated ASCRS clinical practice guidelines for the management of fecal incontinence state that biofeedback may be considered for patients with fecal incontinence (conditional recommendation; quality of evidence: low). The guidelines state that biofeedback is a noninvasive option for patients with fecal incontinence “who have not responded adequately to other conservative measures. The updated guidelines report that nonrandomized, prospective and retrospective studies show 64% to 89% improvement in fecal incontinence with biofeedback, but there are methodological weaknesses with a number of the smaller studies. These study weaknesses, along with randomized controlled trials comparing biofeedback to other treatment options but not to sham therapy, make it difficult to determine a definitive conclusion on the utility of biofeedback. The ASCRS states that in order to determine the efficacy of biofeedback for fecal incontinence, larger, well-designed studies are needed.⁴

American Academy of Neurology (AAN)
The AAN recommends relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive-behavioral therapy as treatment options for prevention of migraine (Grade A). Specific recommendations regarding which of these to use for specific patients cannot be made.⁷ EEG biofeedback is not currently recommended for treating tension or migraine headaches.

Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

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CLINICAL POLICY
Biofeedback

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CLINICAL POLICY
Biofeedback

Important Reminder
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in

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developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of member/enrollees. This clinical policy is not intended to recommend treatment for member/enrollees. Member/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, member/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, member/enrollees and their representatives agree to be bound by such terms and conditions by providing services to member/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid member/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare member/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable

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NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

©2017 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene® and Centene Corporation® are registered trademarks exclusively owned by Centene Corporation.

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