Subject:
Biofeedback
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not normally considered to be under voluntary control. The central feature involves providing the patient with auditory or visual signals from a monitoring device. These signals are the feedback which signify activity from a physiologic variable that is supposed to be related to a given disorder.
Biofeedback is often administered concurrently with relaxation training. Biofeedback treatment regimens begin with a training phase in which the patient receives feedback from the monitoring device. After the patient has achieved success in controlling the physiologic variable and/or clinical symptoms, a long-term maintenance phase is initiated. During maintenance, the subject is often expected to learn to control the condition without feedback.
Policy:
[Please note that Biofeedback may be subject to specific contract limitation or exclusion which takes precedence over this medical policy.]
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Horizon BCBSNJ uses the behavioral health care guidelines from MCG to make behavioral health utilization management determinations related to biofeedback. Upon request, Horizon BCBSNJ will provide the clinical rationale from the MCG care guidelines used in making the adverse benefit determination.
II. The following criteria apply to the use of biofeedback for all other indications:
A. Biofeedback therapy must be ordered by the member’s attending physician.
B. There should be a written treatment plan which must include all of the following information:
1. the specific diagnosis/conditions to be treated
2. long and short term goals
3. measurable objectives
4. the time frame and the frequency of treatment in which the goals and objectives will be achieved.
C. Biofeedback is considered medically necessary for any of the following indications:
1. for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, when conventional treatments (e.g., heat, cold, massage, exercise, support) have been documented to be unsuccessful; (Please note that eligibility of this therapy is limited to the diagnosis of spasm of muscle, and muscular wasting and disuse atrophy. It is not covered for treatment of ordinary muscle tension states or for psychosomatic conditions.)
2. for the treatment of stress and/or urge urinary incontinence in cognitively intact members who have failed trial of pelvic muscle exercise (PME) training (defined as no clinically significant improvement in urinary incontinence after completing 4 weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength).
3. as part of the overall treatment plan for migraine and tension-type headache.
4. for constipation in adult members with dyssynergia-type constipation when all of the following criteria are met:
a. symptoms of functional constipation that meet ROME IV criteria for at least 3 months with symptom onset at least 6 months prior to diagnosis:
i. must include two or more of the following:
- straining during at least 25% of defecations
- lumpy or hard stools in at least 25% of defecations
- sensation of incomplete evacuation for at least 25% of defecations
- sensation of anorectal obstruction/blockage for at least 25% of defecations
- manual maneuvers to facilitate at least 25% of defectations (e.g., digital evacuation, support of the pelvic floor)
- fewer than three defecations per week
ii. loose stools are rarely present without the use of laxatives
iii. insufficient criteria for irritable bowel syndrome
b. objective physiologic evidence of pelvic floor dyssynergia demonstrated by inappropriate contraction of the pelvic floor muscles or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging, or electromyography;
c. failed a 3-month trial of standard treatments for constipation including laxatives, dietary changes, and exercises.
(NOTE: The recommended treatment course for patients with constipation who meet criteria is a maximum of 6 biofeedback sessions over a 3-month period. This is consistent with the protocol used in key randomized trials showing the benefit of biofeedback for selected patients.)
D. Home use of a biofeedback device for the above indications may be eligible in accordance with a treatment plan.
E. All other uses of biofeedback are considered investigational including, but not limited to, cluster headache, chronic pain including low back pain, asthma, sleep bruxism, tinnitus, Bell’s palsy, Raynaud’s disease, orthostatic hypotension in patients with spinal cord injury, hypertension, constipation in children, fecal incontinence in adults and children, pain management during labor, prevention of preterm birth, multiple sclerosis.
Medicare Coverage:
There are several CMS determinations for Biofeedback. Per NCD 30.1, Biofeedback therapy is covered under Medicare only when it is reasonable and necessary for the individual patient for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments (heat, cold, massage, exercise, support) have not been successful. This therapy is not covered for treatment of ordinary muscle tension states or for psychosomatic conditions. For additional information and eligibility, refer to National Coverage Determination(NCD) for Biofeedback Therapy (30.1). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued a Local Coverage Determination (LCD) specific to Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters (L34977) providing limited coverage. For additional information and eligibility, refer to Local Coverage Determination (LCD): Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters (L34977). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46
Biofeedback therapy requires the continuous presence of the physician or a qualified non-physician practitioner (Nurse Practitioner NP, also known as Advanced Practice Nurse (APN) or Physician Assistant (PA)), for a Registered Nurse, Licensed Vocational Nurse, Registered Physical Therapist or Certified Occupational Therapist providing the training. The physician and/or the non-physician practitioner (NP/APN or PA) must provide direct supervision (i.e., the physician or non-practitioner must be present and immediately available to furnish assistance and direction throughout the performance of the procedure) but need not be present in the room when the procedure is performed when the service is rendered in the physician’s office.
Biofeedback training in a group setting is not covered.
Biofeedback training is not covered in the home.
REQUIRED DOCUMENTATION
The medical record documentation must support the medical necessity of the services as directed in this policy. Documentation in the patient's medical record must:
· Indicate the necessity for biofeedback therapy or for diagnostic testing.
· For biofeedback therapy, clearly indicate the failure of pelvic muscle exercise (PME) training.
· Indicate that the patient is capable of learning and performing the treatment program.
· Reflect the number of sessions rendered. Typically, four training sessions are sufficient to teach the biofeedback therapy techniques. Upon post pay review, documentation must demonstrate the need for more than four training sessions.
· Indicate the types of biofeedback training used, patient’s response, educational efforts, and progress
National Coverage Determination (NCD) for Biofeedback Therapy for the Treatment of Urinary Incontinence (30.1.1). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Biofeedback
References:
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100. Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons' clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. Jul 2015;58(7):623-636. PMID 26200676
101. Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. Aug 2014;109(8):1141-1157; (Quiz) 1058. PMID 25022811
102. Paquette IM, Varma M, Ternent C, et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Evaluation and Management of Constipation. Dis Colon Rectum. Jun 2016;59(6):479-492. PMID 27145304
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Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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