Clinical Policy: Biofeedback for Behavioral Health Disorders

Reference Number: CP.BH.300
Date of Last Revision: 06/24
Coding Implications
Revision Log

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

Note: Please refer to the Centene Policy CP.MP.168 for Biofeedback for non-behavioral health diagnoses. This policy is contingent on the member having this benefit.

Description

Biofeedback is a non-invasive technique that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Neurofeedback (NF), often referred to as EEG biofeedback, is a type of biofeedback that involves learning to control and optimize brain function. The characteristic that distinguishes neurofeedback training from other biofeedback is a focus on the central nervous system and the brain.¹

Biofeedback/Neurofeedback is used as an adjunctive tool to other standard interventions and is not used as a stand-alone treatment.²

Policy/Criteria

Clinical Policy

Biofeedback for Behavioral Health Disorders

III. It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that biofeedback is no longer medically necessary and discharge from treatment is medically appropriate when any one of the following is met:
A. The documented goals and objectives have been substantially achieved;
B. The member/enrollee no longer meets initiation or continuation criteria, or symptom severity has dropped by 50%;
C. Member/enrollee is not engaging in treatment, rendering biofeedback ineffective, despite multiple documented attempts to address non-participation issues;
D. Member/enrollee refuses treatment;
E. Member/enrollee is not making progress toward treatment goals and there is no reasonable expectation of progress with this treatment approach;
F. It is reasonably predicted that continuing improvement can occur after discontinuation of biofeedback with ongoing psychotherapy, medication management and/or community support.

IV. It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that current evidence does not support the safety and efficacy of biofeedback for any behavioral health diagnosis other than what is noted in this policy as medically necessary.

V. It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that there is insufficient evidence found in the scientific literature to

Background

During a neurofeedback session, the sensors are placed on the scalp to measure the brain’s electrical activity. During training, sensors are placed on the scalp and then connected to sensitive electronics and computer software that detect, amplify, and record specific brain activity. After this neural information (data) is sent to a computer to be processed, the data is sent back to the brain. The brain then learns to make changes to itself based on this real time data. In Neurofeedback sessions, changes within the brain can be accomplished by either talking directly to the brain electrically, or through stimuli presented to the brain in audio, visual, electrical, magnetic, or tactile form.¹

The practical implementation of neurofeedback and biofeedback as a clinical therapy is currently not regulated regarding the educational standards, medical security, and the usage of standard protocols indicated for specific disorders. Research indicates that there is need for further research into the effectiveness of already available and newly developed neurofeedback protocols.⁴

International Society for Neuroregulation and Research (ISNR)¹

In 2008, the Association for Applied Psychophysiology (AAPB), the Biofeedback Certification International Alliance (BCIA), and the International Society for Neurofeedback and Research (ISNR) approved the following definition of biofeedback. “Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately “feedback” information to the user. The presentation of this information often in conjunction with changes in thinking, emotions, and behavior supports desired physiological changes. Over time, these changes can endure without continued use of an instrument.”
Neurofeedback Training (NFT) has its foundations in basic and applied neurosciences as well as data-based clinical practice. It considers behavioral, cognitive, and subjective aspects as well as brain activity. At a neuronal level, NFT teaches the brain to modulate excitatory and inhibitory patterns of specific neuronal assemblies and pathways based upon the details of the sensor placement and the feedback algorithms used thereby increasing flexibility and self-regulation of relaxation and activation patterns.

The Association for Applied Psychophysiology and Biofeedback²

Biofeedback is NOT used as a treatment alone, nor can it be used alone to make a diagnosis. It should be used as an adjunctive tool to be combined with other standard interventions conducted by knowledgeable clinicians, educators, or coaches. Several biofeedback-based interventions have been well validated while others are at various stages of research. Many biofeedback-based interventions are accepted by medical societies such as the American Colleges of Pediatrics and Neurology as well as by the FDA as being safe and effective for conditions. The efficacy of some forms and uses of biofeedback have not yet been established through accepted types of research with enough clients, controls, and long enough follow-up periods.

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.

*Code may be used for both medically necessary and not medically necessary (i.e., neurosound/biosound) therapies.

Reviews, Revisions, and Approvals

References

1. International Society for Neuroregulation and Research. What is Neurofeedback. https://isnr.org/what-is-neurofeedback. Accessed May 28, 2024.
2. Sherman R., Schwartz P., Andrasik F., et.al, Applied Psychophysiology and Biofeedback. https://aapb.org/Standards_for_Performing_Biofeedback. Published 2013. Accessed May 28, 2024.
3. The Foundation for Peripheral Neuropathy. Biofeedback Therapy. https://www.foundationforpn.org/living-well/integrative-therapies/biofeedback-therapy/. Accessed May 28, 2024.
4. Patil AU, Lin C, Lee SH, et al. Review of EEG-based neurofeedback as a therapeutic intervention to treat depression. Psychiatry Res Neuroimaging. 2023; 329:111591. doi: 10.1016/j.pscychresns.2023.111591
5. Kotthgasser OD, Goreis A, Bauda Z, Ziegenaus A, Glenk LM, Felhofer A. Virtual reality biofeedback interventions for treating anxiety: A systematic review, meta-analysis, and future perspective. Wien Klin Wochenschr. 2022;134(Suppl 1):49-59. doi:10.1007/s00508-021-01991-z
6. Askovic M, Soh N, Elhindi J, Harris AWF. Neurofeedback for post-traumatic stress disorder: systematic review and meta-analysis of clinical and neurophysiological outcomes. Eur J Psychiatrautol. 2023;14(2): 2257435.doi:10.1080/20008066.2023.2257435
7. Pindi P, Houenou J, Piguet C, Favre P. Real-time fMRI neurofeedback as a new treatment for psychiatric disorders: A meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry.2022;119:110605. doi: 10.1016/j.pnpbp.2022.110605
8. Rahmani E, Mahvelati A, Alizadeh A, et al. Is neurofeedback effective in children with ADHD? A systematic review and meta-analysis. Neurocase. 2022;28(1):84-95. doi:10.1080/13554794.2022.2027456
9. Ferreira S, Pégo JM, Morgado P. The efficacy of biofeedback approaches for obsessive-compulsive and related disorders: A systematic review and meta-analysis. Psychiatry Res. 2019; 272:237-245. doi: 10.1016/j.psychres.2018.12.096
10. Enriquez-Geppert S, Smit D, Pimenta MG, Arns M. Neurofeedback as a Treatment Intervention in ADHD: Current Evidence and Practice. Curr Psychiatry Rep. 2019;21(6):46. Published 2019 May 28. doi:10.1007/s11920-019-1021-4
11. National Coverage Determination, (NCD): Biofeedback Therapy (Publication Number 100. 3; Manual Section Number 30.1). Centers for Medicare and Medicaid Services. https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=41. Accessed May 26, 2024.
12. Hou Y, Zhang S, Li N, Huang Z, Wang L, Wang Y. Neurofeedback training improves anxiety trait and depressive symptom in GAD. Brain Behav. 2021;11(3): e02024. doi:10.1002/brb3.2022
13. Tolin DF, Davies CD, Moskow DM, Hofmann SG. Biofeedback and Neurofeedback for Anxiety Disorders: A Quantitative and Qualitative Systematic Review. Adv Exp Med Biol. 2020; 1191:265-289. doi:10.1007/978-981-32-9705-0_16
14. Fernández-Alvarez J, Grassi M, Colombo D, et al. Efficacy of bio- and neurofeedback for depression: a meta-analysis. Psychol Med. 2022;52(2):201-216. doi:10.1017/S0033291721004396
15. Melnikov MY. The Current Evidence Levels for Biofeedback and Neurofeedback Interventions in Treating Depression: A Narrative Review. Neural Plast. 2021; 2021:8878857. Published 2021 Feb 4. doi:10.1155/2021/8878857
16. Patil AU, Lin C, Lee SH, et al. Review of EEG-based neurofeedback as a therapeutic intervention to treat depression. Psychiatry Res Neuroimaging. 2023; 329:111591. doi: 10.1016/j.pscychresns.2023.111591

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 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 medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members 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, members, and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound to such terms and conditions by providing services to members and/or submitting claims for payment for such services.

Note: For Medicaid members, 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 members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable 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.

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