CurrentAmbetter NevadaPolicy CP.MP.168

Clinical Policy: Biofeedback

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

3Professional societies cited

1Insufficient-evidence note

1State precedence

Coverage Criteria for Biofeedback

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Coding and Procedure Codes

Referenced CPT CodesCPT

90901	Biofeedback training by any modality.
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).

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).

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.

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 symptomsDaytime 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.