Humana Commercial Clinical Policy

Humana Biofeedback Form

Effective Date

12/14/2023

Last Reviewed

NA

Original Document

  Reference



Description

Biofeedback is a process that teaches an individual to alter their own autonomic and neuromuscular functions, such as blood pressure, breathing patterns, heart rate, muscle tension and skin temperature. The process utilizes different instruments (e.g., electrocardiogram [ECG], electromyography [EMG]) to give an individual immediate and continuing signals of fluctuations in the bodily function of which they are usually unaware. The goal is to make changes in thinking and behavior by gaining the ability to regulate the processes, and that over time, changes can be continued without the use of biofeedback instruments.

Electroencephalogram (EEG) biofeedback, also known as neurofeedback, uses electroencephalography to illustrate real-time information about brain activity. The goal of EEG biofeedback is to purportedly train an individual to stimulate and suppress brainwaves of specific frequencies. Electrodes that measure EEG signals are attached to the scalp over a section of the brain that is known or believed to have an imbalance in EEG activity. The brainwaves are processed by a programmable biofeedback device that provides feedback for desirable activity through audible or visual cues. Undesirable activity is discouraged by similar means.

(Refer to Coverage Limitations section)

Coverage Determination

Any services for biofeedback that are considered primarily educational or training in nature are generally NOT covered under most Humana benefit Plans. Please consult the member's individual certificate regarding Plan coverage.

Biofeedback may be excluded by certificate as alternative medicine. Please consult the member's individual certificate regarding Plan coverage.

Humana members may be eligible under the Plan for biofeedback for the following indications:

  • Cancer pain; OR
  • Constipation due to dyssynergic defecation in an individual 11 years of age or older; OR
  • Fecal incontinence; OR
  • Functional anorectal pain syndromes (levator ani syndrome, anorectal pain syndrome, proctalgia fugax); OR
  • Migraine headache; OR
  • Tension headache; OR
  • Urinary incontinence

Note: The criteria for biofeedback are not consistent with the Medicare National Coverage Policies and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for biofeedback for any indications other than those listed above including, but may not be limited to:

  • Asthma; OR
  • Attention deficit hyperactivity disorder (ADHD); OR
  • Chronic pain (e.g., fibromyalgia); OR
  • Home biofeedback (e.g., EaseVRx, Freespira, RelieVRx, RESPeRATE, RESPeRATE Deluxe Duo, RESPeRATE Ultra); OR
  • Hypertension (e.g., RESPeRATE, RESPeRATE Deluxe Duo, RESPeRATE Ultra); OR
  • Insomnia; OR
  • Labor pain; OR
  • Panic disorder (e.g., FreeSpira breathing system); OR
  • Post-traumatic stress disorder (PTSD) (e.g., Freespira); OR
  • Spasmodic torticollis; OR
  • Temporomandibular joint disorder (TMD); OR
  • Tinnitus; OR
  • Vulvodynia

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 4 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may NOT be eligible under the Plan for EEG biofeedback (neurofeedback) for any indications including, but may not be limited to:

  • ADHD; OR
  • Anxiety disorder; OR
  • Autism spectrum disorder; OR
  • Depression; OR
  • Migraine headache; OR
  • Obsessive compulsive disorder (OCD); OR
  • Tension headache

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for over-the-counter (OTC) biofeedback devices for any indication. Although they may be prescribed by a health care practitioner, these devices are also available without a prescription and may be obtained OTC and are therefore generally excluded in the certificate. In the absence of a certificate exclusion for OTC items, OTC biofeedback devices are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Background

Additional information about cancer, constipation, migraine headaches or tension headaches may be found from the following websites:

  • American Academy of Neurology
  • American Cancer Society
  • American Gastroenterological Association
  • National Library of Medicine

Medical Alternatives

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 5 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Alternatives to biofeedback for constipation include, but may not be limited to:

  • Dietary changes
  • Enemas
  • Laxatives
  • Prescription drug therapy
  • Suppositories

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

CPT® Code(s)
  • 90875 - Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes
  • 90876 - Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 45 minutes
  • 90901 - Biofeedback training by any modality Not Covered if used to report any treatment outlined in Coverage Limitations section

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 6 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional CPT® Code(s)
  • 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
  • 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)
  • E0746 - Electromyography (EMG), biofeedback device Not Covered for Use in the Home

American Gastroenterological Association medical position statement on constipation. https://www.gastro.org. Published January 2013. Accessed October 24, 2023.

6.American College of Obstetricians and Gynecologists (ACOG). Committee Opinion. Persistent vulvar pain. https://www.acog.org. Published September 2016. Accessed October 24, 2023.

American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin. Fecal incontinence. https://www.acog.org. Published April 2019. Accessed October 24, 2023.

American College of Physicians (ACP). Noninvasive treatments of acute, subacute and chronic low back pain: a clinical practice guideline from the American College of Physicians. https://www.acponline.org. Published April 4, 2017. Accessed October 25, 2023.

10. American Society of Colon and Rectal Surgeons (ASCRS). The American Society of Colon and Rectal Surgeons’ clinical practice guideline for the evaluation and management of constipation. https://www.fascrs.org. Published 2016. Accessed October 25, 2023.

11. American Society of Colon and Rectal Surgeons (ASCRS). The American Society of Colon and Rectal Surgeons’ clinical practice guideline for the treatment of fecal incontinence. https://www.fascrs.org. Published 2023. Accessed October 25, 2023.

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 8 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

12. American Urological Association (AUA). Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUS/SUFU guideline. https://www.auanet.org. Published April 2019. Accessed October 25, 2023.

13. American Urological Association (AUA). Incontinence after prostate treatment: AUA/SUFU guideline. https://www.auanet.org. Published October 2018. Accessed October 25, 2023.

14. American Urological Association (AUA). Surgical treatment of female stress urinary incontinence: AUA/SUFU guideline. https://www.auanet.org. Published March 2017. Updated March 2023. Accessed October 25, 2023.

15. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Biofeedback therapy (30.1). https://www.cms.gov. Accessed October 25, 2023.

16. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Biofeedback therapy for the treatment of urinary incontinence (30.1.1). https://www.cms.gov. Published July 1, 2001. Accessed October 25, 2023.

17. ECRI Institute. Hotline Response. Neurofeedback for treating attention deficit hyperactivity disorder in children and adolescents. https://www.ecri.org. Published March 4, 2020. Accessed October 17, 2023.

18. ECRI Institute. Product Brief. Freespira digital therapeutic (Palo Alto Health Sciences) for treating panic disorder. https://www.ecri.org. Published November 4, 2020. Accessed October 17, 2023.

19. Hayes, Inc. Evolving Evidence Review. Freespira digital therapeutic (Freespira Inc.) for treatment of panic disorder. https://evidence.hayesinc.com. Published May 3, 2022. Updated May 19, 2023. Accessed October 18, 2023.

20. Hayes, Inc. Evolving Evidence Review. Freespira digital therapeutic (Freespira Inc.) for treatment of posttraumatic stress disorder. https://evidence.hayesinc.com. Published August 4, 2022. Updated July 31, 2023. Accessed October 18, 2023.

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 9 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

21. Hayes, Inc.

21. Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). RelieVRx (AppliedVR Inc.) for management of low back pain. https://evidence.hayesinc.com. Published April 11, 2022. Accessed October 18, 2023.

22. Hayes, Inc. Health Technology Brief (ARCHIVED). Biofeedback for the treatment of dysfunctional voiding in children. https://evidence.hayesinc.com. Published March 4, 2009. Updated March 10, 2011. Accessed October 19, 2023.

23. Hayes, Inc. Health Technology Brief (ARCHIVED). RESPeRATE (InterCure Ltd.) device to lower blood pressure. https://evidence.hayesinc.com. Published November 25, 2008. Updated November 23, 2010. Accessed October 19, 2023.

24. Hayes, Inc. Medical Technology Directory (ARCHIVED). Biofeedback for headache and chronic musculoskeletal pain. https://evidence.hayesinc.com. Published November 3, 2004. Updated December 7, 2008. Accessed October 19, 2023.

25. Hayes, Inc. Medical Technology Directory (ARCHIVED). Biofeedback therapy for the treatment of hypertension. https://evidence.hayesinc.com. Published February 27, 2006. Updated April 20, 2010. Accessed October 18, 2023.

26. Hayes, Inc. Medical Technology Directory (ARCHIVED). Biofeedback therapy for vulvodynia. https://evidence.hayesinc.com. Published March 18, 2008. Updated March 27, 2012. Accessed October 18, 2023.

27. Hayes, Inc. Medical Technology Directory (ARCHIVED). Electroencephalogram (EEG) biofeedback therapy. https://evidence.hayesinc.com. Published April 11, 2003. Updated March 13, 2008. Accessed October 19, 2023.

28. Hayes, Inc. Medical Technology Directory (ARCHIVED). Nonpharmacological treatments for attention-deficit/hyperactivity disorder (ADHD): neurofeedback. https://evidence.hayesinc.com. Published July 15, 2009. Updated July 9, 2013. Accessed October 19, 2023.

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 10 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

29. MCG Health. Biofeedback. 27th edition. https://www.mcg.com. Accessed October 23, 2023.

30. MCG Health. Pelvic floor rehabilitation. 27th edition. https://www.mcg.com. Accessed October 23, 2023.

31. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Adult cancer pain. http://www.nccn.org. Updated July 31, 2023. Accessed October 25, 2023.

32. North American Society for Pediatric Gastroenterology, Hepatology and nutrition (NASPGHAN). Clinical Guideline. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. https://www.naspghan.org. Published February 2014. Accessed October 25, 2023.

33. UpToDate, Inc. Attention deficit hyperactivity disorder in children and adolescents: overview of treatment and prognosis. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.

34. UpToDate, Inc. Autism spectrum disorder in children and adolescents: complementary and alternative therapies. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.

35. UpToDate, Inc. Chronic functional constipation and fecal incontinence in infants, children and adolescents: treatment. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.

36. UpToDate, Inc. Chronic migraine. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.

37. UpToDate, Inc. Complementary, alternative and integrative therapies for asthma. https://www.uptodate.com. Updated September 2023. Accessed October 19, 2023.

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 11 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.

Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. UpToDate, Inc. Complementary and integrative health in pediatrics. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.
  2. UpToDate, Inc. Constipation in the older adult. https://www.uptodate.com. Updated September 2023. Accessed October 20, 2023.
  3. UpToDate, Inc. Fecal incontinence in adults: management. https://www.uptodate.com. Updated September 2023. Accessed October 20, 2023.
  4. UpToDate, Inc. Female urinary incontinence: treatment. https://www.uptodate.com. Updated September 2023. Accessed October 20, 2023.
  5. UpToDate, Inc. Functional constipation in infants, children and adolescents: clinical features and diagnosis. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.
  6. UpToDate, Inc. Management of bladder dysfunction in children. https://www.uptodate.com. Updated September 2023. Accessed October 19, 2023.
  7. UpToDate, Inc. Management of chronic constipation in adults. https://www.uptodate.com. Updated September 2023. Accessed October 19, 2023.
  8. UpToDate, Inc. Nonpharmacologic approaches to management of labor pain. https://www.uptodate.com. Updated September 2023. Accessed October 20, 2023.
  9. UpToDate, Inc. Obstetric anal sphincter injury (OASIS). https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 12 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. UpToDate, Inc. Preventive treatment of migraine in children. https://www.uptodate.com. Updated September 2023. Accessed October 20, 2023.
  2. UpToDate, Inc. Preventive treatment of episodic migraine in adults. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.
  3. UpToDate, Inc. Proctalgia fugax. https://www.uptodate.com. Updated September 2023. Accessed October 20, 2023.
  4. UpToDate, Inc. Rehabilitative and integrative therapies for pain in patients with cancer. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.
  5. UpToDate, Inc. Sleep-related bruxism (tooth grinding). https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.
  6. UpToDate, Inc. Solitary rectal ulcer syndrome. https://www.uptodate.com. Updated September 2023. Accessed October 20, 2023.
  7. UpToDate, Inc. Temporomandibular disorders in adults. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.
  8. UpToDate, Inc. Tension-type headache in adults: preventive treatment. https://www.uptodate.com. Updated September 2023. Accessed October 19, 2023.
  9. UpToDate, Inc. Tension-type headache in children. https://www.uptodate.com. Updated September 2023. Accessed October 23, 2023.
  10. UpToDate, Inc. Treatment of tinnitus. https://www.uptodate.com. Updated September 2023. Accessed October 20, 2023.

Biofeedback Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0409-019
Page: 13 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

US Department of Veterans Affairs (VA). VA/DoD clinical practice guideline for diagnosis and treatment of low back pain. https://www.va.gov. Published 2022. Accessed October 25, 2023.

US Department of Veterans Affairs (VA). VA/DoD clinical practice guideline for the management of chronic multisymptom illness.

US Department of Veterans Affairs (VA).

VA/DoD clinical practice guideline for the management of chronic multisymptom illness. https://www.va.gov. Published 2021. Accessed October 26, 2023.

59. US Department of Veterans Affairs (VA). VA/DoD clinical practice guideline for the management of major depressive disorder. https://www.va.gov. Published February 2022. Accessed October 26, 2023.

60. US Department of Veterans Affairs (VA). VA/DoD clinical practice guideline for management of headache. https://www.va.gov. Published September 2023. Accessed October 26, 2023.