Anthem Blue Cross Connecticut MED.00125 Biofeedback and Neurofeedback Form

This document addresses biofeedback, a treatment method where an individual is given information, via an electronic monitor, about physiological processes that are normally involuntary, such as blood pressure, muscle tension, heart rate, and other bodily functions. The individual then uses this information to gain voluntary control and modify those processes. Examples of biofeedback techniques include thermal biofeedback, where the individual is provided information on skin temperature, and electromyographic (EMG) biofeedback, where the individual is provided information on muscle tension.

Neurofeedback (also known as EEG biofeedback) is a type of biofeedback that uses electroencephalograms (EEGs) as the feedback source. EEG information is signaled to the individual, usually by video or sound, for the purpose of training the individual to self-regulate brain activity. Neurofeedback is being studied for a variety of medical and psychological conditions.

Note: Neurofeedback (EEG biofeedback) should not be confused with electroencephalograms (EEGs) used for the diagnosis of neurological disorders.

Position Statement

Medically Necessary:

Biofeedback therapy is considered medically necessary when the following criteria are met:

1. Supervised by a physician or licensed practitioner; and
2. Used as treatment for at least one of the following conditions:
   1. Cancer pain; or
   2. Chronic back pain as part of a rehabilitation program; or
   3. Chronic constipation; or
   4. Fecal incontinence; or
   5. Levator ani syndrome, also known as anorectal pain syndrome; or
   6. Migraine or tension headaches; or
   7. Urinary incontinence.

Investigational and Not Medically Necessary:

Biofeedback therapy is considered investigational and not medically necessary when the criteria above are not met, and for all other indications.

Neurofeedback, also known as electroencephalogram (EEG) biofeedback, is considered investigational and not medically necessary for all indications including, but not limited to:

1. asthma;
2. attention-deficit hyperactivity disorder;
3. autistic spectrum disorders;
4. cardiovascular conditions;
5. cluster headaches;
6. epilepsy;
7. post-traumatic stress disorder;
8. substance use disorders;
9. traumatic brain injury.

The use of home biofeedback devices is considered investigational and not medically necessary for all indications.