Sunflower Health Plan Biofeedback for Behavioral Health Disorders (PDF) Form

Biofeedback or neurofeedback is a noninvasive technique intended to enable an individual to learn how to change a physiological activity for the purpose of improving health and performance. It employs instruments that measure physiological activities such as brainwaves, heart rate, breathing rate, muscle activity and skin temperature. Biofeedback is a process in which a patient learns to increase or decrease specific brain activity using real-life feedback from a scalp electroencephalogram (EEG). Patients are encouraged to increase desired brain activity and decrease undesired activity. Policy/Criteria I. It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation® that up to 25 sessions of initial behavioral health-related biofeedback is medically necessary if all the following are met: A. Diagnosis of anxiety disorder or post-traumatic stress disorder as listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders; B. There are significant symptoms that interfere with the member/enrollee’s ability to function in at least one life area as measured by a widely recognized validated standardized severity scale focused on the symptom profile; C. The member/enrollee is motivated to actively participate in the treatment plan, including being responsive to the care plan requirements (e.g., practice and follow-through at home); D. The individual is capable of participating in the treatment plan (physically as well as intellectually); E. The condition can be appropriately treated with biofeedback (e.g., existing pathology does not prevent success of the treatment); F. There is evidence that standard evidence-based outpatient treatments (including psychotherapy and medication management) are considered insufficient to safely and effectively treat the patient’s condition; G. There is a readily identifiable response measurable by a symptom specific validated standardized scale; H. Biofeedback training is performed by a physician or qualified non-physician practitioner who has undergone biofeedback training and certification. This can include nurse practitioners, physician assistants, qualified mental health professionals, psychologists and, where applicable, biofeedback technicians; I. Treatment plan is individualized with clearly stated realistic goals and objectives; J. Treatment is structured to achieve optimum benefit and expected benefit is documented Page 1 of 7 CLINICAL POLICY Biofeedback for Behavioral Health Disorders K. There is documented planned transition out of biofeedback from the start of treatment, which may include ensuring the ability of the patient to continue the biofeedback-learned techniques independently after the biofeedback sessions end. II. It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation that continuation of behavioral health-related biofeedback is medically necessary if all the following are met: A. Initial criteria are still met; B. The frequency of sessions is scheduled to occur at a rate consistent with the presenting symptoms and showing results, while a lower rate may impede progress; C. Progress related to biofeedback can be clearly described by at least a 25% reduction in severity, as compared to the baseline severity score; D. When medically necessary, appropriate psychopharmacological intervention is provided; E. There is documented planned transition out of biofeedback from the start of treatment, which may include ensuring the ability of the patient to continue the biofeedback-learned techniques independently after the biofeedback sessions end. 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 are 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 biofeedback 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. Background During biofeedback, the patient is seated in a comfortable chair facing a computer screen. Electrodes are placed on the patient’s scalp. Target brain waves and event-related potentials are recorded and processed by an electroencephalograph and computer; concurrently, presented (‘fed back’) to the patient, typically as a visual representation (e.g., a ball moving up or down to signify fast and slow-wave activity), or in the format of a video game. Feedback for desirable activity may include sounds or visual cues (e.g., smiley face), points, or increased control in the Page 2 of 7 CLINICAL POLICY Biofeedback for Behavioral Health Disorders computer game. Undesirable activity is discouraged by similar means. Patients are instructed to use the feedback to regulate their brain activity. Sessions last between 30 and 60 minutes and up to 25 sessions are scheduled. A therapist is typically present to facilitate learning (e.g., asks the patient about strategies that seem successful, encourages the patient to try different strategies until a successful one is identified). Patients are instructed to practice strategies at home between sessions. These instruments offer almost instant “feedback” information to the user. The presentation of this information along with changes in thinking, emotions and behavior, may support learning of a skill set of techniques leading to desirable physiological changes. Over time, such changes may endure or the learned skills may be applied without the continued use of an instrument. Biofeedback has been used to treat children and adults with anxiety and PTSD. It has been typically performed in the outpatient setting and it is usually not provided as a stand-alone treatment, but in conjunction with other therapies such as psychotherapy and medication management. Biofeedback for behavioral health conditions generally do not meet the criteria standard as an evidence-based treatment. Although not conclusive, the treatment of anxiety disorders using neurofeedback is mostly based on observational history and case reports. There is weak scientific evidence found in the nationally recognized literature about the efficacy of Neurosound/Biosound treatment as applied to billing under the Neurofeedback CPT code. CABH will not authorize Neurosound/Biosound under the Neurofeedback CPT code. 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 2021, 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. CPT® Codes 90901 90876 90875 Biofeedback training by any modality 45 minutes of individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy 30 minutes of individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with patient), with psychotherapy ICD-10-CM Diagnosis Codes that Support Coverage Criteria Page 3 of 7 CLINICAL POLICY Biofeedback for Behavioral Health Disorders ICD 10 CM Code - - F41.1 Generalized Anxiety Disorder F43.10, F43.11, F43.12 Post-Traumatic Stress Disorder, unspecified, acute or chronic Revision Date 05/20 Approval Date 5/20 5/21 6/21 F41.0 Panic Disorder Reviews, Revisions, and Approvals CBH Clinical Policy CP.BH.300 Neurofeedback for Behavioral Health Disorders adapted from MHN Clinical Policy HNCA.CP.MP.162 Neurofeedback for Behavioral Health Disorders. Annual review. Changed Centene Behavioral Health with Centene Advanced Behavioral Health. Revisions: Revision to Section: • The FDA has not approved this treatment as safe and effective for any condition. CMS has not approved this treatment as Reasonable and Necessary for any condition. It currently remains Experimental and Investigational. Revision to Policy and Criteria Section, I. B, and F, G and H • There are significant symptoms that interfere with the individual’s ability to function in at least one life area as measured by a widely recognized validated standardized severity scale focused on the symptom profile; • There is evidence that standard evidence-based outpatient treatments (including psychotherapy and medication management) are considered insufficient to safely and effectively treat the patient’s condition • There is a readily identifiable response measurable by a symptom specific validated standardized scale; • Neurofeedback training is performed by a physician or qualified non-physician practitioner who has undergone neurofeedback training and certification. This can include nurse practitioners, physician assistants, qualified mental health professionals, psychologists and where applicable biofeedback technicians Background Section Update: • Neurofeedback for behavioral health conditions generally do not meet the criteria standard as an evidence-based treatment. Although not conclusive, the treatment of anxiety disorders using neurofeedback is mostly based on observational history and case reports. section, section I, Policy Criteria, sections B, F, G & H; and the last paragraph in the background section. References reviewed and updated. Page 4 of 7 Revision Date 5/22 Approval Date 6/22 11/22 12/22 CLINICAL POLICY Biofeedback for Behavioral Health Disorders Reviews, Revisions, and Approvals Annual review conducted. Neurofeedback references changed to biofeedback to align with the Centene Policy CP.MP.168 for Biofeedback for non-behavioral health diagnoses; Added references to CMS NCD - Biofeedback Therapy (30.1) and FDA approved as Class II; and 45 minutes to CPT code 90875, and 30 minutes to CPT code 90876. Adhoc Review. “Last Review Date” in policy header changed to “Date of Last Revision,” and “Date” in the revision log was changed to “Revision Date.” Removed description paragraph pertaining to NCD biofeedback verbiage and FDA approval. Replaced all instances of “patient” with “member/enrollee”. Replaced “or” and “commas” with “semi-colons. Replaced all instances of the statement: “It is the policy of Centene Advanced Behavioral Health (CABH)” with the statement “It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation”. Incorporated treatment plan information into section I. I-K. In section III.B, replaced the word “admission” with “initiation or continuation criteria”. In section IV, replaced “Experimental/investigational” verbiage with “current evidence does not support the safety and efficacy of biofeedback,”. Removed verbiage pertaining to state criteria for biofeedback. Removed verbiage between the ICD-10 coding table and revision log that referred to LCDs and/or state regulations taking precedence, as this is duplicative with the policy disclaimer. Removed references related to ADHD severity scales as ADHD is not an included indication. Updated coding implications verbiage to reflect 2021 AMA copyright. Replaced all instances of “dashes (-) in page numbers with the word “to”.