CurrentBlue Cross Blue Shield - MassachusettsPolicy 173

Biofeedback for urinary incontinence (outpatient/inpatient coverage)

This Blue Cross Blue Shield Massachusetts medical policy (Policy Number 173, BCBSA Ref 2.01.27) addresses coverage of biofeedback as a treatment for urinary incontinence in adults, including outpatient and inpatient settings, coding, prior authorization requirements, evidence summary, and related policies. It specifies investigational status for biofeedback services/devices and precertification requirements when performed inpatient.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyBiofeedback for urinary incontinence (outpatient/inpatient coverage)

Policy CodePolicy 173

Change TypeAnnual review; coding clarification

Effective Date

Next Review Date

Key ActionPrecertification/preauthorization is required for all products if the biofeedback procedure is performed inpatient.

POLICY UPDATE CHANGES

Annual policy review: Policy updated with literature review through August 20, 2024; references added; Pelvic Health System added to evidence review on women with urinary incontinence.

4/2024 Clarified coding information.

10/2023 Annual policy review: Description, summary, and references updated.

InvestigationalOutpatient coverage status

RequiredInpatient precertification

S9002, 90875-90876, 90901, 90912-90913Key codes listed

Coverage Summary

Scope: This Blue Cross Blue Shield Massachusetts medical policy (Policy Number 173, BCBSA Ref 2.01.27) addresses coverage of biofeedback as a treatment for urinary incontinence in adults across outpatient and inpatient settings, including coding, prior authorization requirements, evidence summary, and related policies.

Overview: Biofeedback for urinary incontinence is described in the policy as an investigational service for outpatient treatment in adults, with precertification required when the procedure is performed inpatient. The policy specifies that biofeedback services and related devices are considered investigational and provides coding information and prior authorization guidance; annual reviews and coding clarifications were performed with literature updates through August 20, 2024.

Key Facts

Coverage status (outpatient biofeedback)Investigational

Precertification for inpatientRequired

Key codes listedS9002, 90875-90876, 90901, 90912-90913

Medical-Necessity Criteria

Medical Coverage Determination

Coverage statements for biofeedback as a treatment of urinary incontinence:

ALL of the following

Biofeedback in the outpatient setting as a treatment of urinary incontinence in adults is investigational
Unsupervised home use of biofeedback for treatment of urinary incontinence is investigational

Prior Authorization / Precertification

Preauthorization requirements for services described in this policy:

ANY of the following

For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient
For outpatient services described in this policy, prior authorization may be required depending on product (Commercial PPO and Indemnity: outpatient is not a covered service)

Provider Actions & Billing Impact

Prior Authorization

Precertification required for inpatient biofeedback procedures

Precertification/preauthorization is required for all products if the biofeedback procedure is performed inpatient.

Documentation Required

Verify member contract benefits

Providers must refer to the member's contract benefits in effect at the time of service to determine coverage or noncoverage. Inclusion of codes in the policy is informational and does not imply coverage.

The codes listed in the policy are for informational purposes only and do not guarantee member coverage or provider reimbursement.

Denial Risk

Outpatient biofeedback not covered for certain products

Commercial PPO and Indemnity outpatient biofeedback is described as not a covered service; claims for outpatient biofeedback for these products may be denied.

Commercial PPO and Indemnity: outpatient biofeedback is not a covered service and prior authorization may not make it payable.
Claims for outpatient biofeedback for these products may be denied.

Coding

Investigational CPT codes (policy states investigational)CPTExperimental

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

Investigational HCPCS code (policy states investigational)HCPCSExperimental

S9002

Intra-vaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device

Informational / general coding guidancemixed

No codes listed

Inclusion of CPT and HCPCS codes in this policy is for informational purposes only and does not constitute or imply member coverage or provider reimbursement; providers must verify the member’s contract benefits at the time of service. Precertification/preauthorization is required for all products if the biofeedback procedure is performed inpatient.

Background & Evidence Summary

Biofeedback is a technique that provides feedback about physiologic processes to teach self-regulation and has been proposed for treatment of a variety of disorders, including urinary incontinence. Methods described in the policy include vaginal cones or weights, perineometers, and electromyographic systems with vaginal and rectal sensors; biofeedback is frequently used in conjunction with pelvic floor muscle training (PFMT) to enhance awareness and learning of pelvic muscle exercises.

Evidence Summary

Comparative effectivenessRCTs and systematic reviews show mixed results; no consistent evidence that biofeedback added to PFMT improves continence rates.

ConclusionEvidence is insufficient to determine that biofeedback improves net health outcome for urinary incontinence in women or post-prostatectomy patients.

Name	Number	Effective Date	Type
National coverage decision for biofeedback therapy for urinary incontinence	30.1.1	2001	NCD

Definitions

Biofeedback: Technique to teach self-regulation of physiologic processes via feedback signals (eg, lights, tones, verbal cues) to alter monitored physiologic variables; used alone or with other therapies (eg, pelvic floor muscle training) and implemented via devices/methods such as vaginal cones, perineometers, and electromyographic systems.

Revision History

2023-10annual_review_revised

Annual policy review: Description, summary, and references updated; policy statements unchanged.

2024-04clarified_coding

Clarified coding information.

2024-08-20literature_review_update

Annual policy review: Policy updated with literature review through August 20, 2024; references added; Pelvic Health System added to evidence review on women with urinary incontinence; policy statements unchanged.