CurrentBlue Cross Blue Shield - MassachusettsPolicy 152

Biofeedback for Headache Treatment Policy

Defines medical necessity and investigational determinations for biofeedback when used to treat migraine, tension-type, and cluster headaches for Commercial members (Managed Care, PPO, Indemnity); outlines prior authorization requirements for inpatient care and outpatient prior auth rules by product, and lists applicable CPT and ICD-10 diagnosis codes.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyBiofeedback for Headache Treatment Policy

Policy CodePolicy 152

Change TypeAnnual review; clarifications and coding updates

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient biofeedback services and follow product-specific outpatient prior authorization rules; when billing CPT 90875, 90876, or 90901 submit an applicable ICD-10 headache diagnosis and ensure medical necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

1/2023: Medicare information removed; see separate Medicare policy for LCD/NCD references.

1/2023: Previously 'Not medically necessary' policy statement for an indication was changed to 'Investigational'.

10/2023: Clarified coding information.

1/2026: Annual policy review; literature updated through September 19, 2025; policy statements unchanged.

2Covered Indications (migraine, tension-type)

1Investigational Indication (cluster headache)

Coverage Summary

Overview: This policy addresses Biofeedback for Headache Treatment and defines medical necessity and investigational determinations for commercial members (Managed Care, PPO, Indemnity). It specifies that biofeedback may be considered medically necessary as part of the overall treatment plan for migraine and tension-type headache, and that biofeedback for cluster headache and unsupervised home use is investigational. Effective/last review date: Last review: 2026-01. Policy status: CURRENT.

Medical Necessity / Investigational Determinations

Medically Necessary (Commercial Members)

Covered when ALL of the following are met:

ALL of the following

Member has a diagnosis of migraine or tension-type headache listed in the policy (ICD-10 codes provided)
Biofeedback is provided as part of the overall treatment plan for migraine or tension-type headache

Investigational / Not Medically Necessary

ANY of the following

Biofeedback for the treatment of cluster headache is investigational
Unsupervised home use of biofeedback for treatment of headache is investigational

Evidence summary: Systematic reviews and meta-analyses for migraine and tension-type headache provide sufficient evidence to conclude improvement in net health outcome (reduction in frequency and/or severity).

By contrast, evidence for cluster headache is limited to small case series and case reports with no controlled trials identified; this evidence is insufficient to determine benefit.

Coding

Covered CPT Codes (when medical necessity criteria are met)CPTCovered

90875	Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy; approx 20-30 minutes
90876	Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy; approx 45-50 minutes
90901	Biofeedback training by any modality

Applicable Diagnosis Codes (medically necessary when submitted with CPT above and criteria met)ICD-10Covered

G43.001	Migraine without aura, not intractable, with status migrainosus
G43.009	Migraine without aura, not intractable, without status migrainosus
G43.011	Migraine without aura, intractable, with status migrainosus
G43.019	Migraine without aura, intractable, without status migrainosus
G43.101	Migraine with aura, not intractable, with status migrainosus
G43.109	Migraine with aura, not intractable, without status migrainosus
G43.111	Migraine with aura, intractable, with status migrainosus
G43.119	Migraine with aura, intractable, without status migrainosus
G43.401	Hemiplegic migraine, not intractable, with status migrainosus
G43.409	Hemiplegic migraine, not intractable, without status migrainosus

1–10 of 54

1/6

Provider Actions & Authorization

Prior Authorization

Inpatient Precertification/Preauthorization Required

Precertification/preauthorization is required for all products when the biofeedback services described in this policy are performed inpatient.

Prior Authorization

Outpatient Prior Authorization Varies by Product

Outpatient prior authorization is not required for Commercial Managed Care (HMO and POS), PPO, and Indemnity products per the policy; check product-specific rules for other products where outpatient prior authorization might be required.

Background & Definitions

Background: Biofeedback teaches self-regulation of physiologic processes (for example, skin temperature, blood-volume-pulse, and EMG). It is typically delivered in 10–20 training sessions of about 30 minutes each, provided in individual or group sessions, and may be used alone or together with other therapies (eg, relaxation, behavioral management, medication).

Clinical contexts studied include migraine and tension-type headaches (with evidence supporting reductions in frequency and/or severity), while studies of cluster headache are limited and have not shown sufficient evidence of benefit.

Definitions:

Biofeedback: Technique intended to teach individuals self-regulation of physiologic processes not normally under voluntary control (eg, skin temperature, blood-volume-pulse, EMG).

Medicare Determinations

Name	Number	Type	Effective Date
National Coverage Determination for Biofeedback Therapy	30.1	NCD

Revision History

11/2015clarified

Clarified coding information.

2/2018clarified

Clarified coding information.

10/2023clarified

Clarified coding information.