Arizona Complete Health biofeedback Coverage Update

Coverage Criteria for Biofeedback (Behavioral Health)

Initial Therapy

Covered when ALL of the following are met for initial treatment (up to 25 sessions):

Initial coverage criteria: A. Diagnosis of anxiety disorder or PTSD as listed in DSM V-TR; B. Significant symptoms interfering with at least one life area measured by a validated standardized severity scale focused on the symptom profile; C. Member is motivated to and can actively participate in the treatment plan, including practice and follow-through at home; D. Biofeedback is included in a comprehensive treatment plan as an adjunctive intervention in addition to other primary evidence-based interventions; E. The condition can be appropriately treated with biofeedback (existing pathology does not prevent success); F. Standard evidence-based outpatient treatments (including psychotherapy and/or medication management) are considered insufficient to treat the member's condition safely and effectively; 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 (may include NPs, PAs, qualified mental health professionals, psychologists, and where applicable, biofeedback technicians); I. An individualized treatment plan with clearly stated realistic goals and objectives is documented; J. Treatment is structured to achieve optimum benefit with expected benefit documented; K. There is a documented planned transition out of biofeedback from the start of treatment (e.g., ensuring the member can continue learned techniques independently).

Initial authorization allows up to 25 sessions.

Continuation Therapy

Continuation reviewed case-by-case (up to an additional 20 sessions):

Continuation criteria: A. The initial criteria continue to be met; B. Frequency of sessions is scheduled at a rate consistent with presenting symptoms and showing results; C. Progress is clearly described by at least a 25% reduction in severity compared to the last review; D. When medically necessary, appropriate psychopharmacological intervention is provided; E. There is a documented planned transition out of biofeedback from the start of treatment, which includes: 1) a plan ensuring the member can continue biofeedback-learned techniques independently after sessions end; and 2) a goal with a clear and reasonable score range on a validated scale demonstrating meaningful progress.25% improvement

Medical Director reviews continuation requests; up to an additional 20 sessions will be reviewed on a case-by-case basis.

Discharge / No Longer Medically Necessary

Discontinuation / No longer medically necessary when ANY of the following are met:

Discharge criteria: A. Documented goals and objectives have been achieved; B. Member no longer meets initiation or continuation criteria, or symptom severity has dropped by 50%; C. Member is not engaging in treatment despite multiple documented attempts, rendering biofeedback ineffective; D. Member refuses treatment; E. Member is not making progress toward treatment goals with no reasonable expectation of progress with this approach; F. It is reasonably predicted that continuing improvement can occur after discontinuation with ongoing psychotherapy, medication management and/or community support.50% reduction for discharge

Triggers discharge from biofeedback.

Unsupported Indications / Modalities

Not covered / insufficient evidence:

Unsupported indications and modalities: There is insufficient evidence in the published peer-reviewed literature to support use of biofeedback for behavioral health diagnoses other than anxiety disorders and PTSD; there is insufficient evidence to support neurosound/biosound interventions (often billed under neurofeedback CPT codes).

Use outside specified indications or neurosound/biosound treatments are considered not supported by evidence and not covered.

Neurosound/biosound treatment (often marketed as audio-based or sound-modulated neurofeedback) lacks sufficient peer-reviewed evidence to support its use for behavioral health conditions and is not supported by this policy. The policy was clarified to add an explicit statement that neurosound/biosound interventions are considered unsupported due to insufficient scientific evidence and therefore should not be authorized under this coverage determination.

There is insufficient published peer‑reviewed evidence to support the use of biofeedback for behavioral health diagnoses other than anxiety disorders and post‑traumatic stress disorder (PTSD). Biofeedback outside these specified indications is considered not medically necessary under this policy and may be denied when requested for other psychiatric diagnoses.

Billing and Coding

Referenced CPT codesCPT

90901	Biofeedback training by any modality
90875	30 minutes of individual psychophysiological therapy incorporating biofeedback training
90876	45 minutes of individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy

Provider Actions and Requirements

Prior Authorization

Prior authorization and session limits

Up to 25 initial outpatient biofeedback sessions require prior authorization and documentation that the member meets the policy's eligibility criteria; requests for up to an additional 20 continuation sessions will be reviewed case-by-case by a Medical Director.

Initial authorization allows up to 25 sessions when all initiation criteria are met.
Continuation requests (up to 20 additional sessions) are reviewed by a Medical Director and require documentation of ongoing eligibility and progress.

Step Therapy

Adjunctive treatment requirement

Biofeedback must be included only as an adjunctive intervention within a comprehensive treatment plan and documentation must show that standard outpatient evidence-based treatments (psychotherapy and/or medication management) were considered insufficient.

Biofeedback must be adjunctive to other primary evidence-based interventions.

Background and Rationale

Biofeedback provides real‑time physiologic monitoring (for example heart rate variability, EEG/neurofeedback, respiration, muscle tension, and skin temperature) to teach self‑regulation skills and is intended to be used as an adjunct to established treatments such as psychotherapy and/or medication management. The policy recognizes some evidence supporting biofeedback for anxiety disorders and PTSD in systematic reviews and meta‑analyses but emphasizes variability in protocols and provider qualifications; consequently, coverage is limited to those diagnoses with documented criteria and required documentation, while modalities and indications without sufficient evidence (including neurosound/biosound) are not supported.

Definitions

inv-13: Biofeedback — instruments & physiologic signals monitored

Monitored signalsBrainwave patterns (EEG), heart rate/heart rate variability (HRV), respiration, muscle tension (EMG), and skin temperature.

Instruments usedPrecise physiologic monitoring instruments and electrical sensors applied to specific body sites to capture real-time signals.

Feedback modalitiesReal-time auditory and visual cues (e.g., beeping sounds, flashing lights) provided to the patient to facilitate recognition of physiologic responses.

PurposeProvide real-time physiologic data to teach self-regulation techniques and produce positive physical changes in response to stress.

inv-14: Adjunctive use — biofeedback as adjunctive tool, not standalone

Adjunctive requirement

Level of Care — Outpatient Criteria

Treatment Modalities: Biofeedback and Neurofeedback

Biofeedback / Neurofeedback

Biofeedback modality guidance: Includes HRV, neurofeedback, respiration, muscle tension, and skin temperature monitoring; biofeedback is a technique providing real-time physiologic monitoring and feedback to teach self-regulation skills; it must be performed by a qualified clinician and used as an adjunct to psychotherapy and/or medication management; certain modalities (neurosound/biosound) lack sufficient evidence and are not supported by this policy.

Modalities should follow qualified protocols and be part of a comprehensive individualized treatment plan.

Visit and Session Limits

inv-17: Outpatient biofeedback sessions — visit limits and review

Initial session limitUp to 25 outpatient biofeedback sessions are allowed for initial treatment when all coverage criteria are met.

Continuation sessionsUp to an additional 20 sessions may be reviewed on a case-by-case basis by a Medical Director.

Continuation review thresholdContinuation requires documented progress of at least a 25% reduction in severity compared to the last review.

Authorization basisContinuation requests are reviewed by a Medical Director and require that initial criteria remain met and session frequency is appropriate and showing results.

OpenPayer

Biofeedback for Behavioral Health Disorders