CurrentBlue Cross Blue Shield - MassachusettsPolicy 173

Biofeedback for Urinary Incontinence

This policy describes the coverage stance for biofeedback (including devices and training) used to treat urinary incontinence in adults for Blue Cross Blue Shield - Massachusetts commercial products and specifies authorization requirements for inpatient and outpatient settings.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyBiofeedback for Urinary Incontinence

Policy CodePolicy 173

Change TypeClarified codingliterature updateevidence addition

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for inpatient biofeedback services described in this policy.

SourceLink

POLICY UPDATE CHANGES

Clarified coding information.

Policy updated with literature review through October 3, 2025; references added.

leva® Pelvic Health System added to evidence review on women with urinary incontinence.

173Policy

Not coveredOutpatient stance

InvestigationalClinical stance

Precert requiredInpatient auth

CPT/HCPCS

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Evidence Summary

Commercial Member Coverage Stance

Covered when ALL of the following are met

Commercial coverage stance: 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.

Evidence Summary

Summary of clinical evidence informing coverage

Women with urinary incontinence: Randomized controlled trials and systematic reviews comparing pelvic floor muscle training (PFMT) with and without biofeedback report mixed results: some reviews found improvements for some outcomes but a comparative effectiveness review did not find a statistically significant difference in continence rates. Overall, evidence is inconsistent and insufficient to demonstrate an improvement in net health outcome.

Relevant outcomes include symptoms, functional outcomes, and quality of life.

Post-prostatectomy and preoperative use: RCTs and systematic reviews of PFMT with versus without biofeedback after radical prostatectomy show mixed results and generally do not consistently report improved outcomes when biofeedback is added. One systematic review found preoperative biofeedback reduced postoperative incontinence, but the certainty of evidence was low to very low due to heterogeneity and imprecision. Overall evidence is insufficient to demonstrate improved net health outcome; timing and delivery of the intervention were not well-defined in studies.

Additional well-designed trials are needed to demonstrate superiority of biofeedback with PFMT over PFMT alone.

For Blue Cross Blue Shield of Massachusetts commercial members, outpatient biofeedback for the treatment of urinary incontinence in adults is not a covered service for Managed Care (HMO and POS) products and is also reported as not covered for Commercial PPO and Indemnity outpatient settings. The policy further designates outpatient biofeedback for urinary incontinence as investigational for commercial members.

This policy references the Centers for Medicare & Medicaid Services National Coverage Decision (NCD) for biofeedback therapy for the treatment of urinary incontinence (NCD 30.1.1, 2001). The NCD is cited as part of the policy references but the specific NCD coverage language or restrictions are not reproduced in these sections.

The policy states that unsupervised home use of biofeedback for treatment of urinary incontinence is investigational and therefore not supported by this coverage policy for commercial members.

Coding — CPT/HCPCS and Related Items

Investigational CPT Codes (Commercial Members)CPTNot Covered

90875	Individual psychophysiological therapy incorporating biofeedback training by any modality; approximately 20-30 minutes
90876	Individual psychophysiological therapy incorporating biofeedback training by any modality; approximately 45-50 minutes
90901	Biofeedback training by any modality
90912	Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry; initial 15 minutes
90913	Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry; each additional 15 minutes

Investigational HCPCS Codes (Commercial Members and Medicare HMO/PPO)HCPCSNot Covered

S9002

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

Coding — Additional metadata

Investigational CPT codes (Commercial)90875; 90876; 90901; 90912; 90913

Code descriptions90875: Individual psychophysiological therapy incorporating biofeedback training (~20-30 min); 90876: ~45-50 min; 90901: Biofeedback training by any modality; 90912: Biofeedback training perineal muscles/anorectal/urethral sphincter, initial 15 min; 90913: each additional 15 min

Coverage statusListed as investigational / not covered for commercial members (per policy)

Billing guidanceProviders should report services using up-to-date procedure and diagnosis codes; inclusion in policy does not guarantee coverage

Provider Actions, Authorization, and Billing Guidance

Prior Authorization

Inpatient precertification required

For services described in this policy, precertification/preauthorization IS REQUIRED when the procedure is performed inpatient for all products.

Applies to all products when service is inpatient.

Denial Risk

Outpatient coverage and denial risk

Outpatient biofeedback services for Commercial Managed Care (HMO and POS) are not a covered service and may be denied when billed for outpatient settings. Providers should verify member contract benefits for Commercial PPO and Indemnity members to determine coverage.

Commercial Managed Care (HMO and POS), Outpatient = not a covered service.
Commercial PPO and Indemnity, Outpatient = verify member contract benefits.

Background

Biofeedback is a technique intended to teach voluntary control or self-regulation of physiologic processes using feedback signals (for example, EMG or pressure sensors) and is commonly used in conjunction with pelvic floor muscle training to treat urinary incontinence. Typical programs involve multiple training sessions using modalities such as surface EMG, pressure sensors or other feedback devices to guide pelvic floor muscle exercises aimed at improving stress, urge, mixed, or overflow incontinence.

Definitions

Biofeedback — definition and modalities

DefinitionBiofeedback is a technique to teach self-regulation of physiologic processes not generally considered under voluntary control, using external feedback to modify those processes.

Typical feedback modalitiesElectromyography (EMG), pressure sensors (perineometers, manometry), vaginal cones/weights, peripheral skin temperature and blood-volume-pulse feedback.

Common program structureTypically delivered in multiple training sessions (commonly 10–20 sessions of ~30 minutes each) in a quiet setting, often combined with pelvic floor muscle training.

Intended use with pelvic floor trainingUsed in conjunction with pelvic floor muscle training to enhance awareness and learning of pelvic floor exercises for stress, urge, mixed, and overflow urinary incontinence.

biofeedback / pelvic floor muscle training — referenced interventions