CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Biofeedback Therapy for Urinary Incontinence — Coverage and Prior Authorization

This policy governs coverage and prior authorization requirements for biofeedback therapy (including EMG and perineal biofeedback) used to treat urinary incontinence for Blue Cross & Blue Shield of Rhode Island members, distinguishing Medicare Advantage from Commercial product rules.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyBiofeedback Therapy for Urinary Incontinence — Coverage and Prior Authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization via the web-based tool for Medicare Advantage plans for the listed biofeedback codes before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5-6Expected trial visits

10-20Typical program length

Medicare onlyCoverage stance

6 codesCodes listed

Coverage Criteria

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Coding

Codes requiring preauthorization for Medicare Advantage / Listed codesmixed

90875	Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy; 30 minutes
90901	Biofeedback training by any modality
90876	Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy; 45 minutes
90912	Biofeedback training, perineal muscles, anorectal or urethral sphincter, including electromyography; initial 15 minutes
90913	Biofeedback training, perineal muscles, anorectal or urethral sphincter; additional 15 minutes (add-on)
E0746	Electromyography (EMG), biofeedback device

Commercial product non-covered codes / contract exclusionsmixedNot Covered

90875	Non-covered for Commercial Products - Individual psychophysiological therapy incorporating biofeedback; 30 minutes
90876	Non-covered for Commercial Products - Individual psychophysiological therapy incorporating biofeedback; 45 minutes
90901	Non-covered for Commercial Products - Biofeedback training by any modality
90912	Non-covered for Commercial Products - Biofeedback perineal muscles, initial 15 minutes
90913	Non-covered for Commercial Products - Biofeedback perineal muscles, additional 15 minutes
E0746	Non-covered for Commercial Products - Electromyography (EMG), biofeedback device

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization for biofeedback is required for Medicare Advantage plans and must be obtained via the online tool for participating providers.

Use the online prior authorization tool for participating providers (Medicare Advantage only).

Denial Risk

Trial Length and Continuation

Biofeedback trial therapy should be limited to an initial course of 5–6 retraining visits. Patients who do not demonstrate functional improvement within that trial are unlikely to benefit from additional biofeedback sessions.

Trial length: 5–6 visits; continuation beyond this requires documented improvement or strong clinical justification.
If patient does not show improvement after 5–6 visits, additional sessions are subject to denial without supporting documentation.

Documentation Required

Failure to Show Improvement — Documentation Needed to Continue Therapy

If the patient fails to show improvement during the 5–6 visit trial, additional biofeedback sessions will require documentation that justifies medical necessity and supports expectation of benefit. Lack of documented improvement is a denial risk for continued therapy.

Documented evidence of improvement during the trial (clinical notes, objective measures) is expected.
If requesting >6 sessions, include clear rationale explaining why additional treatment is likely to be effective and what different or intensified interventions will be used.

Documentation Required

Required Clinical Elements for Initial and Continued Therapy

For Medicare Advantage plans, ensure documentation demonstrates the patient is capable, the condition is appropriate for biofeedback, and the patient is motivated to participate in the plan of care.

Documentation should include: capability to participate, medical indication showing biofeedback is appropriate, and evidence of patient motivation and adherence (eg, home practice, caregiver support).
Clinical records should align with CMS NCD/LCD medical necessity criteria where applicable.

Billing Rule

Commercial Product Exclusion — Non-covered Codes

For Commercial products, biofeedback services and the listed codes are contract exclusions and claims will be non-covered.

Non-covered / contract exclusion for Commercial Products: CPT 90875, 90876, 90901, 90912, 90913; HCPCS E0746.

Background

Biofeedback trains patients to voluntarily modify physiologic processes (for urinary incontinence this typically means pelvic floor muscle activity) by providing real-time feedback from sensors such as EMG or manometry. It is commonly paired with pelvic floor muscle training and usually delivered as a series of sessions (typical programs are about 10–20 sessions of roughly 30 minutes each) to teach and reinforce muscle control and coordination.

When used for urinary incontinence, biofeedback aims to improve continence by helping patients identify and strengthen the appropriate muscles, improve coordination, and promote adherence to home practice; Medicare Advantage coverage is contingent on the patient being capable of participation, the condition being amenable to biofeedback, and the patient being motivated to follow the treatment plan.

Definitions

inv-13: Biofeedback — definition and examples of physiologic variables

DefinitionA technique that provides feedback on physiologic variables (eg, EMG, skin temperature, blood-volume pulse) to teach voluntary control of parameters not normally under conscious control.

Typical training program10–20 sessions of about 30 minutes each, performed in a quiet environment with feedback delivered as lights, tones, verbal praise, or other auditory/visual signals.

Common clinical usesUsed with pelvic floor muscle training for stress, urge, mixed, and overflow urinary incontinence; also proposed for anxiety, headaches, hypertension, movement disorders, pain, asthma, Raynaud disease, and insomnia.

Feedback modalities (examples)Peripheral skin temperature, blood-volume-pulse (vasoconstriction/dilation), vasoconstriction training, and electromyographic (EMG) feedback.

Sensors/examples for pelvic floorVaginal or rectal sensors, vaginal cones/weights, perineometers, and EMG systems are commonly used to provide feedback during pelvic floor training.

inv-14: Perineal/EMG biofeedback — definition and typical monitoring methods

DefinitionBiofeedback training that monitors perineal muscles or anorectal/urethral sphincter activity, often using electromyography and sometimes manometry.

Typical monitoring methodsElectromyographic (EMG) systems with vaginal and rectal sensors; perineometers; manometry may be used when performed alongside EMG.

Coding examples (per source)Procedure codes include 90912 (initial 15 minutes perineal/EMG) and 90913 (each additional 15 minutes; add-on).

Device exampleE0746 — Electromyography (EMG), biofeedback device, used to capture and relay perineal muscle activity.