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    v1.0.28
    OpenPayerPolicy UpdatesNeurology/NeurosurgeryBlue Cross Blue Shield MA Biofeedback Coverage | O…
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    CurrentBlue Cross Blue Shield - MassachusettsPolicy 152

    Biofeedback for Headache Disorders

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    This policy governs coverage of biofeedback therapy for primary headache disorders (migraine, tension-type, and cluster headache) for Blue Cross Blue Shield Massachusetts members and describes authorization, coding, and medical necessity criteria for Commercial products.

    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    PolicyBiofeedback for Headache Disorders
    Policy CodePolicy 152
    Change TypeNo material changes
    Effective Date
    Last ReviewSep 16, 2024
    Next Review Date
    Key ActionObtain precertification/preauthorization when the procedure is performed inpatient to avoid denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    10-20typical number of sessions
    30-60 min

    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.

    session duration
    90875/90876/90901CPT codes listed
    G43/G44ICD-10 codes
    Precert requiredinpatient auth

    Coverage Criteria

    inv-01: Medically Necessary Indications — Covered when criteria for the specific headache disorder are met:

    Covered when criteria for the specific headache disorder are met:

    Migraine and Tension-type Headache: Biofeedback may be considered MEDICALLY NECESSARY as part of the overall treatment plan for migraine and tension-type headache.

    Systematic reviews and meta-analyses of controlled and uncontrolled studies demonstrate reduction in frequency and/or severity of migraine and tension-type headaches; evidence is sufficient to conclude improvement in net health outcome.

    inv-02: Investigational / Not Medically Necessary Indications — Not covered / investigational when:

    Not covered / investigational when:

    Cluster Headache: Biofeedback for treatment of cluster headache is INVESTIGATIONAL.

    Evidence consists of small case series and case reports; no controlled trials identified and evidence is insufficient to demonstrate improvement in net health outcome.

    Unsupervised Home Use: Unsupervised home use of biofeedback for treatment of headache is INVESTIGATIONAL.

    Policy explicitly states unsupervised home use is investigational (not covered).

    Unsupervised home use of biofeedback for the treatment of headache is considered INVESTIGATIONAL and is not covered. This policy specifies that biofeedback provided without clinical supervision in the home setting does not meet medical necessity criteria.

    Biofeedback for the treatment of cluster headache is considered INVESTIGATIONAL and therefore not medically necessary. The evidence for cluster headache consists only of small case series and case reports, and no controlled trials were identified, yielding insufficient evidence to demonstrate improvement in net health outcomes.

    Coding

    Covered CPT Codes (informational list in policy)CPT
    90875Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy; approximately 20-30 minutes.
    90876Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy; approximately 45-50 minutes.
    90901
    ICD-10 Diagnosis Codes considered medically necessary when submitted with listed CPT codesICD-10
    G43.001Migraine without aura, not intractable, with status migrainosus
    G43.009Migraine without aura, not intractable, without status migrainosus
    G44.201Tension-type headache, unspecified; intractable
    G43.011Migraine without aura, intractable, with status migrainosus
    G43.019Migraine without aura, intractable, without status migrainosus
    G43.101Migraine with aura not intractable, with status migrainosus
    G43.109Migraine with aura, not intractable, without status migrainosus
    G43.111Migraine with aura, intractable, with status migrainosus
    G43.119Migraine with aura, intractable, without status migrainosus
    G43.401Hemiplegic migraine, not intractable, with status migrainosus
    1–10 of 50
    1/5

    Provider Actions & Billing Rules

    Prior Authorization

    Prior Authorization Required

    Precertification/preauthorization is required for services described in this policy when performed inpatient for all products. Failure to obtain required inpatient precertification/preauthorization may result in claim denial or delayed payment. Providers must verify member benefits and obtain authorization prior to inpatient admission.

    • Applies to all products when procedure is performed inpatient
    • Obtain precertification/preauthorization before inpatient services to avoid denial
    Prior Authorization

    Outpatient Prior Authorization

    Outpatient prior authorization requirements vary by product. For certain products or settings, outpatient prior authorization may be required; Commercial PPO and Indemnity plans do not require prior authorization for outpatient services under this policy. Always verify the member's contract and product-specific rules before scheduling outpatient procedures.

    • Commercial PPO and Indemnity — Outpatient prior authorization is not required
    • Other products/plans — outpatient prior authorization may be required; check product rules

    Background

    Migraine, tension-type, and cluster headaches are primary headache disorders with distinct clinical presentations: migraine often involves severe unilateral, throbbing pain frequently accompanied by nausea and sensory sensitivity; tension-type headache is typically less intense and bilateral; and cluster headache causes brief, severe attacks that can occur multiple times per day. Biofeedback is a behavioral technique that provides patients with physiologic feedback to enable voluntary regulation of physiologic processes; when combined with relaxation and other therapies, systematic reviews and meta-analyses indicate it can reduce the frequency and/or severity of migraine and tension-type headaches. Typical biofeedback programs involve multiple training sessions (commonly 10–20 sessions of approximately 30–60 minutes each).

    Definitions

    inv-12: Biofeedback — Definition and program characteristics
    DefinitionFeedback of physiologic information not normally available to the patient, used with training to enable voluntary alteration of targeted physiologic processes (eg, via lights, tones, or verbal feedback).
    Training formatDelivered in individual or group sessions, alone or combined with other behavioral therapies (eg, relaxation).
    Typical programUsually 10–20 training sessions of 30–60 minutes each conducted in a quiet, nonarousing environment.
    Feedback methodsFeedback may be visual or auditory signals (lights, tones), verbal praise, or other stimuli provided when the physiologic parameter is altered successfully.
    Patient roleSubjects use mental techniques and practice to modify monitored physiologic variables guided by feedback.
    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    PolicyBiofeedback for Headache Disorders
    Policy CodePolicy 152
    Change TypeNo material changes
    Effective Date
    Last ReviewSep 16, 2024
    Next Review Date
    Key ActionObtain precertification/preauthorization when the procedure is performed inpatient to avoid denial.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & Billing RulesBackgroundDefinitions
    Step Therapy

    Step Therapy

    No step therapy requirements are specified in this policy. If a product implements step therapy for related services or therapies, providers should follow the specific product-level step therapy protocols.

    Documentation Required

    Coding and Documentation Guidance

    Providers should report all services using current procedure (CPT/HCPCS), revenue, and diagnosis (ICD-10) codes and applicable modifiers. Inclusion of a code in policy does not guarantee coverage or reimbursement; verify member benefits. The medical necessity criteria in this policy must be met for listed codes to be eligible for coverage.

    • Use most up-to-date industry-standard codes and modifiers
    • Inclusion of codes is informational only; check member contract for coverage
    • Medical necessity criteria must be met for code coverage
    Denial Risk

    Inpatient Prior Authorization Requirement

    Failure to obtain required inpatient precertification/preauthorization may trigger denial of the claim or other adverse payment actions. Confirm authorization requirements and obtain approvals prior to inpatient procedures to avoid denial risk.

    • Denial risk if inpatient precertification/preauthorization is not obtained
    • Verify and document authorization prior to inpatient service
    inv-13: Thermal biofeedback — Technique and use
    DefinitionA biofeedback technique in which patients learn to increase peripheral skin temperature (eg, fingertip) via imagery and relaxation with feedback from a temperature sensor.
    MechanismIncreases peripheral vasodilation mediated through sympathetic activity by providing feedback on skin temperature.
    Common useCommonly employed for migraine headache, often combined with relaxation training to improve symptoms.
    Equipment and procedureA temperature sensor is placed on the finger and subjects are taught to raise fingertip temperature using imagery/relaxation while receiving real-time feedback.
    Related techniquesOther biofeedback modalities include blood-volume-pulse feedback, vasoconstriction training, and electromyographic biofeedback which may be used alone or with thermal biofeedback.