CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy — Biofeedback

Defines coverage, prior authorization, coding, and medical necessity criteria for biofeedback therapy for BlueCHiP for Medicare and states commercial contract stance; affects providers billing Blue Cross Blue Shield - Rhode Island plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyBiofeedback (Medical Coverage Policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2001

Next Review DateN/A

Key ActionObtain prior authorization for specified biofeedback procedure codes for BlueCHiP for Medicare and document a failed PME trial before requesting biofeedback for urinary incontinence unless medical justification is provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5-6expected trial length

90901,90911-13,90875-76,E0746codes discussed

exclusioncommercial stance

requiredprior auth

Coverage and Medical Necessity Criteria

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Covered indications (BlueCHiP for Medicare)

Biofeedback is covered when ALL of the following BlueCHiP for Medicare criteria are met (as specified below):

Medicare urinary incontinence with intact pelvic floor: For treatment of stress and/or urge urinary incontinence when there is evidence that the floor musculature is intact

Indications list: One of: treatment of pathological muscle abnormalities (spasticity, incapacitating spasm, weakness) after failure of conventional treatments; muscle re-education of specific muscle groups; treatment of stress/urge incontinence in cognitively intact patients who failed a documented trial of pelvic muscle exercise (PME) training

Failed PME defined as no clinically significant improvement after >= 4 weeks of an ordered PME plan

Patient participation and prognosis: Patient capable of participation in plan of care and motivated to follow therapy; condition appropriately treatable with biofeedback (no pathology preventing success)

Patients not improving after 5-6 visits are unlikely to improve further without additional justification

Procedure and Billing Codes

Specified biofeedback CPT codes (preauthorization required / contract status varies)CPT

90901	Biofeedback training by any modality
90911	Biofeedback perineal muscles, anorectal or urethral sphincter; including EMG and/or manometry (deleted as of 12/31/2019)
90912	Biofeedback training, perineal muscles, anorectal or urethral sphincter, including electromyography (EMG) and/or manometry, initial 15 minutes
90913	Biofeedback training, perineal muscles, anorectal or urethral sphincter; each additional 15 minutes

Psychophysiological therapy codesCPT

90875	Individual psychophysiological therapy incorporating biofeedback training by any modality (~20-30 minutes) with psychotherapy
90876	Individual psychophysiological therapy incorporating biofeedback training by any modality (~45-60 minutes) — listed as non-covered

Durable medical equipment HCPCSHCPCSNot Covered

E0746

Electromyography (EMG), biofeedback device

inv-08: PME trial duration — >= 4 weeks

Operational threshold>= 4 weeks

ContextDefined as duration of an ordered pelvic muscle exercise (PME) plan before biofeedback may be considered for urinary incontinence

ApplicabilityRequired for determining a failed PME trial when considering biofeedback for stress/urge urinary incontinence under BlueCHiP for Medicare

inv-09: Biofeedback trial visits before unlikely improvement — 5-6 visits

Visits threshold5-6 visits

InterpretationPatients not showing improvement after 5-6 biofeedback retraining visits are unlikely to improve with additional sessions

Documentation implicationAdditional documentation required to justify biofeedback services beyond 5-6 visits

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for specified biofeedback procedure codes for BlueCHiP for Medicare. Documentation must support any deviation from standard PME trial requirements and justify extended therapy beyond typical visit limits.

Preauthorization applies to CPT codes 90901, 90911, 90912, 90913 (see coding).

Documentation Required

PME Trial Requirement for Incontinence

For urinary incontinence, biofeedback may be allowed only after a failed, documented trial of pelvic muscle exercise (PME) training unless there is medical justification to bypass PME. A failed PME trial is defined as no clinically significant improvement in urinary continence after completing 4 or more weeks of an ordered PME plan designed to increase periurethral muscle strength.

PME trial: minimum 4 weeks of an ordered PME plan.
Biofeedback may be initial treatment only when the physician documents medical justification and rationale for why PME trial was not attempted first.

Documentation Required

Documentation for PME Waiver and Extended Therapy

When a PME trial is bypassed or when additional biofeedback sessions beyond the usual course are requested, documentation must include medical justification and rationale. For BlueCHiP for Medicare, medical record documentation should show why PME was not appropriate or feasible and provide clinical evidence to support extended therapy.

If PME trial is bypassed: physician-written justification explaining why PME was not attempted and why biofeedback is clinically necessary.
If requesting more than 5–6 biofeedback visits: objective documentation of improvement potential and clinical rationale; patients not showing improvement after 5–6 visits are unlikely to benefit from additional sessions and require strong justification for continuation.

Denial Risk

Non‑covered Indications / Contract Exclusion

Coverage differs by product: for BlueCHiP for Medicare biofeedback is covered when medical criteria are met, but it is considered not medically necessary for ordinary muscle tension states, psychosomatic conditions, home use, and other indications not specifically listed. For Commercial products, biofeedback is a contract exclusion / non‑covered service.

Not medically necessary (BlueCHiP for Medicare) for ordinary muscle tension states, psychosomatic conditions, home use, and conditions not listed as covered.
Commercial Products: biofeedback is a contract exclusion / non-covered service.

Key Definitions

inv-15: Definition of Biofeedback

DefinitionBiofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not normally considered under voluntary control, using feedback (visual, auditory, thermal, EMG, manometry) to enable voluntary control.

Feedback modalitiesVisual, auditory, thermal, EMG, manometry (and peripheral skin temperature, blood-volume-pulse) depending on the condition treated

PurposeProvides evidence of body function status so voluntary control can be exerted to alter an abnormal physiological condition

inv-16: Failed PME trial

DefinitionNo clinically significant improvement in urinary continence after completing 4 or more weeks of an ordered pelvic muscle exercise (PME) plan.

Use in policyThis definition establishes when a PME trial is considered failed for purposes of permitting biofeedback for urinary incontinence under BlueCHiP for Medicare

Exception noteBiofeedback may be allowed initially only when physician documents medical justification why a PME trial was not attempted first