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    v1.0.28
    OpenPayerPolicy UpdatesPhysical Medicine, Rehab & TherapiesAmbetter Nevada Biofeedback Coverage Update | Open…
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    CurrentAmbetter NevadaPolicy CP.MP.168

    Clinical Policy: Biofeedback

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    Medical necessity and coverage criteria for biofeedback therapy across specified clinical indications for members/enrollees of the health plan.

    Policy Summary
    PayerAmbetter Nevada
    PolicyClinical Policy: Biofeedback
    Policy CodePolicy CP.MP.168
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain and document a trial and failure of conservative therapies (e.g., four-week pelvic muscle exercise training for adult urinary incontinence) and submit prior authorization using CPT 90901, 90912, or 90913 as applicable.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    7Covered indications
    3CPT codes referenced

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3Professional societies cited
    1Insufficient-evidence note
    1State precedence

    Coverage Criteria for Biofeedback

    Coverage Criteria for Biofeedback

    Medically Necessary Indications — Covered when ALL of the following are met:

    title':'Medically Necessary Indications — Covered when ALL of the following are met:','type':'criteria_group'

    Coding and Procedure Codes

    Referenced CPT CodesCPT
    90901Biofeedback training by any modality.
    90912Biofeedback 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.
    90913Biofeedback 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).
    Coding metadata (N/A)
    Coding thresholdsN/A — no utilization thresholds or limits specified in this policy.
    Coding statusCPT codes referenced elsewhere in the policy; this metadata block contains no codes.
    Documentation requirementUse referenced CPT codes and document medical necessity per Health Plan rules; see coding and provider action sections for details.

    Provider Actions, Authorization & Documentation

    Prior Authorization

    Prior Authorization per Health Plan

    Prior authorization may be required by the member's specific Ambetter Nevada plan. Providers should verify prior authorization requirements with the Health Plan before initiating biofeedback services and submit any required prior authorization requests per plan-level procedures.

    • Prior authorization may be required per member's Ambetter Nevada plan — confirm prior to scheduling services.
    • When requesting prior authorization, include relevant clinical documentation supporting medical necessity (see documentation callout).
    • Use CPT codes 90901, 90912, and 90913 as applicable when requesting coverage and on claims submission; inclusion of codes does not guarantee coverage.
    Documentation Required

    Documentation of Prior Conservative Therapy and Coding

    Document a trial and failure (or intolerance) of conservative therapies when required by the criteria. For urinary incontinence, document a trial of pelvic muscle exercise training (e.g., a minimum four-week trial) and evidence that biofeedback is being used as an adjunct when appropriate. For dysfunctional voiding in children, document prior use of alternatives (e.g., timed voiding, prophylactic antibacterial therapy, short-term anticholinergic medication).

    Background on Biofeedback Therapy

    Biofeedback provides real-time visual or auditory feedback of physiological signals (for example, EMG, heart rate, or skin temperature) to help patients learn voluntary control over body functions. This modality is used as an adjunct to pelvic floor muscle training for urinary incontinence, to teach children with dysfunctional voiding to better coordinate pelvic floor muscles, and to retrain pelvic floor coordination in defecatory disorders and fecal incontinence.

    Definitions and Key Terms

    Biofeedback therapy
    DefinitionTherapy using visual, auditory, or other feedback of body functions (e.g., heart rate, muscle tone) often via electrical devices to permit voluntary control and reduction of abnormal bodily conditions.
    MechanismDevices transform physiologic signals (EMG, heart rate, skin temperature, etc.) into tones or lights that reflect activity level to guide voluntary control.
    Clinical roleUsed as an adjunct to pelvic floor muscle training and to teach patients control of targeted muscle groups or physiologic functions.
    Dysfunctional voiding (children)
    DefinitionA learned behavior of abnormal urination in children characterized by inappropriate contraction of pelvic floor muscles to suppress bladder contractions, often causing daytime wetness and urinary tract infections.
    Typical symptoms
    Policy Summary
    PayerAmbetter Nevada
    PolicyClinical Policy: Biofeedback
    Policy CodePolicy CP.MP.168
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain and document a trial and failure of conservative therapies (e.g., four-week pelvic muscle exercise training for adult urinary incontinence) and submit prior authorization using CPT 90901, 90912, or 90913 as applicable.
    SourceLink
    On This Page
    Coverage Criteria for BiofeedbackCoding and Procedure CodesProvider Actions, Authorization & DocumentationBackground on Biofeedback TherapyDefinitions and Key Terms
    • Document the conservative therapy type, start and end dates, patient adherence and response to therapy.
    • Include relevant diagnostic findings and any objective testing (e.g., anorectal manometry when indicated for fecal incontinence).
    • Relevant CPT codes for biofeedback services: 90901, 90912, 90913 — list codes on authorization requests and claims as applicable.
    Documentation Required

    Provider Documentation and Judgment

    Providers must document medical necessity and apply professional judgment when recommending biofeedback. The Health Plan's clinical policy is a guide to medical necessity and coverage decisions remain subject to the member's contract, plan rules, exclusions, and limitations. Providers remain responsible for treatment decisions and should supply thorough clinical justification when submitting requests or appeals.

    • Include clinical assessment, diagnosis, rationale for biofeedback, prior treatments tried, patient capacity to participate, and expected goals of therapy.
    • If the member is a child, document caregiver support available to facilitate participation in the plan of care.
    • Be aware that coverage decisions are subject to Health Plan-level administrative policies and state Medicaid provisions where applicable.
    Daytime wetness, urinary tract infections, urgency, frequency, infrequency, and constipation.
    Usual careTimed voiding, voiding diaries, and pelvic floor exercises; biofeedback reserved when conservative therapy and/or pharmacotherapy are unsuccessful.
    Medical necessity guide
    PurposeThis clinical policy is a guide to medical necessity used to assist in making coverage decisions and administering benefits.
    LimitationsIt does not constitute a contract or guarantee regarding payment or results; coverage remains subject to the member's coverage documents and applicable laws.
    Development basisDeveloped by licensed health care professionals based on standards of medical practice, peer-reviewed literature, guidelines, and other clinical information.
    Health Plan
    DefinitionHealth 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 affiliates.
    Authority and applicationThe Health Plan may determine the effective date of this policy and retains the right to change, amend or withdraw it; plan-level administrative policies apply.
    Coverage precedenceState Medicaid provisions take precedence over this policy when conflicts exist; Medicare NCDs/LCDs should be reviewed for Medicare members.