CurrentCentenePolicy CP MP.168

Clinical Policy: Biofeedback

Defines medical necessity criteria, background, and coding implications for biofeedback therapy for members/enrollees of Centene-affiliated health plans. Affects clinicians and billing staff requesting/performing biofeedback.

Policy Summary

PayerCentene

PolicyClinical Policy: Biofeedback

Policy CodePolicy CP MP.168

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when billing biofeedback services with CPT codes 90901, 90912, or 90913.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT codes referenced

7Named covered indications

11/24Last revision

NotedMedicaid precedence

Coverage Criteria for Biofeedback

Medically Necessary Indications

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General requirements: Member/enrollee is cognitively and physically capable of participating in the agreed upon plan of care and motivated to actively participate in the treatment plan (if a child, support and guidance are available to fulfill the plan of care).

Documented ability and motivation to participate; include parental/caregiver support for children.

Indications

Adult urinary incontinence: Urinary incontinence (stress, urge, or mixed) in adult members/enrollees who have failed a documented four-week trial of pelvic muscle exercise training.
Four-week documented trial of pelvic muscle exercise training required prior to biofeedback.
Dysfunctional voiding in children when conservative alternatives have been unsuccessful (e.g., timed voiding, voiding diaries, prophylactic antibacterial therapy for recurrent UTIs, short-term anticholinergic medications); biofeedback reserved for those who have failed adequate conservative therapy and/or pharmacotherapy.
Used to retrain pelvic floor coordination; requires prior adequate trial of conservative therapy.
Fecal incontinence with demonstration of external anal sphincter weakness on anorectal manometry.
Contraindications (see exclusions) must be absent; anorectal manometry required to demonstrate external anal sphincter weakness.
Chronic constipation (defecatory disorders): Chronic constipation due to defecatory disorders where biofeedback can be used to train pelvic floor relaxation and coordination during defecation.
Indicated for patients with defecatory disorder physiology; often after failure of conservative measures.
Tension or migraine headaches for which biofeedback is used as a therapeutic modality.
Biofeedback may be used to reduce muscle tension or autonomic contributors to headache.
Chronic pain where biofeedback is employed to assist in symptom management and self-regulation techniques.
Used as adjunctive therapy for chronic pain conditions.
Muscle re-education of specific muscle groups for treating pathological muscle abnormalities such as spasticity, incapacitating spasm, or weakness.
Applied to defined muscle groups for rehabilitation objectives.

Contraindications and condition-specific requirements for fecal incontinence: biofeedback is indicated only when anorectal manometry demonstrates weakness of the external anal sphincter. The policy lists specific contraindications for use in fecal incontinence, including: isolated internal anal sphincter weakness; decreased ability to perceive rectal distension because of nerve injury; neurological disorders associated with substantial loss of rectal sensation and/or inability to contract the external anal sphincter; decreased rectal storage capacity from resection, inflammation, or fibrosis; and suspected or established major structural damage to continence mechanisms.

The policy also identifies situations where biofeedback is inappropriate or unlikely to be effective, for example overflow incontinence associated with behavioral or psychiatric disorders. These contraindications were added and clarified in policy revisions to ensure appropriate patient selection and to avoid offering biofeedback when structural, neurologic, or sensory deficits preclude benefit.

Coverage determinations under this clinical policy are guidances to assist in medical necessity decisions; they do not replace the members benefit plan. Coverage and payment remain subject to the members specific coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract of insurance) and any applicable state or federal requirements. Providers and billing staff should verify benefits, prior authorization rules, and any exclusions or limitations in the members plan before scheduling or billing biofeedback services.

Use of biofeedback for indications other than the specific conditions enumerated in this policy is considered to have insufficient evidence to establish safety and efficacy. The policy explicitly states there is insufficient evidence to support biofeedback for any conditions beyond the listed indications (for example, urinary incontinence, dysfunctional voiding in children, fecal incontinence, chronic constipation/defecatory disorders, tension/migraine headaches, chronic pain, and selected muscle re-education). Such uses should be treated as not medically necessary or investigational until adequate evidence supports them.

Coding and Billing

Referenced CPT CodesCPT

90901	Biofeedback training by any modality.
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.

No codes listed in this document segmentmixed

No codes listed

Coding: thresholds and notes

Coding thresholdsNone specified in this document segment.

NoteCoding and billing are governed by the Health Plan and applicable coverage documents.

ActionRefer to the Coding section or contact Provider Services for applicable CPT guidance.

Provider Actions, Documentation & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for biofeedback services billed with CPT codes 90901, 90912, and 90913. Obtain prior authorization before delivering services to ensure coverage consideration.

Affected CPT codes: 90901, 90912, 90913

Note

Prior Authorization Guidance

This clinical policy is intended to be used as a guide to medical necessity determinations and claims administration. Coverage decisions and benefit administration remain subject to the terms, conditions, exclusions, and limitations of the member's coverage documents and applicable laws/regulations.

Denial Risk

Denial Risk — Conservative Therapy Not Documented

Lack of documentation showing a documented four‑week trial of pelvic muscle exercise training for adult members with urinary incontinence may result in denial of biofeedback services. Providers should document the trial, including start/end dates, instructions given, and patient response.

Requirement: Documented 4‑week trial of pelvic muscle exercise training for adult urinary incontinence prior to biofeedback requests

Documentation Required

Documentation Requirements

Documentation must support that the member is cognitively and physically able and motivated to participate in the agreed upon plan of care (for children, documentation should reflect available caregiver support and guidance to assist with home practice). Include objective findings, prior conservative treatments tried, treatment goals, and progress notes demonstrating participation and response.

Document cognitive and physical ability and motivation to participate
For children, document caregiver support and plan for home practice
Include prior treatments, treatment goals, session notes, and measurable response

Documentation Required

Pediatric Dysfunctional Voiding — Prior Conservative Measures Required

For dysfunctional voiding in children, biofeedback is indicated only after failure of conservative measures (for example: timed voiding/scheduled voids, voiding diaries, pelvic floor exercises, behavioral interventions, prophylactic antibiotics for recurrent UTIs, and short‑term anticholinergic therapy when appropriate). Documentation should describe the specific conservative measures attempted, duration, and outcomes.

Clearly list conservative therapies tried and duration (e.g., timed voiding, voiding diaries, pelvic floor exercises)
Describe outcomes and rationale for escalation to biofeedback

Note

Professional Judgment and Documentation Responsibility

Providers are expected to exercise professional medical judgment and are responsible for maintaining complete documentation to support medical necessity. The Health Plan will review submitted documentation when assessing prior authorization requests and claims.

Background on Biofeedback

Biofeedback is a behavioral rehabilitative technique that uses physiologic monitoring to provide real-time feedback, allowing patients to learn voluntary control of bodily functions. Common modalities referenced in this policy include electromyography (EMG) biofeedback to measure and train muscle tension (frequently used for pelvic or perineal muscle training), thermal biofeedback which measures skin temperature to guide relaxation and autonomic control, and other device-based feedback methods. The therapeutic intent is to retrain muscle coordination, improve sphincter function, reduce maladaptive patterns (for example dysfunctional voiding in children), and augment pelvic floor muscle training for conditions such as urinary or fecal incontinence, defecatory disorders, headache, chronic pain, or targeted muscle re-education for spasticity or debilitating muscle weakness.

Per the policy, biofeedback is delivered by physicians or qualified non-physician practitioners (including therapists and advanced practice clinicians) and is intended as an adjunct to conventional behavioral and rehabilitative measures rather than as a standalone cure; appropriate patient selection and the ability of the member to participate and follow through with the plan of care are required for medical necessity.

Definitions and Modalities

EMG biofeedback (electromyography-based)

DefinitionElectromyography (EMG) biofeedback measures muscle tension to provide feedback for training pelvic and other skeletal muscles.

Typical useUsed as an adjunct to pelvic floor muscle exercises to improve ability to perform exercises and for muscle re-education (e.g., spasticity, weakness).

ProvidersPerformed by physicians or qualified non-physician practitioners, including therapists and advanced practice clinicians.

Thermal biofeedback (skin temperature-based)

DefinitionThermal biofeedback measures skin temperature to provide feedback aimed at relaxation and autonomic control.

Clinical contextOne of the commonly used biofeedback modalities; applied in conditions where autonomic or relaxation training is beneficial.

DeliveryAdministered by trained clinicians as part of biofeedback therapy programs.

Neurofeedback (EEG)

DefinitionNeurofeedback (EEG) is electroencephalography-based biofeedback that measures brain wave activity to provide feedback for self-regulation.

Scope noteNeurofeedback (EEG) is noted separately with respect to behavioral health indications; see related behavioral health policy (e.g., CP.BH.300).

UsageOne of the three most commonly used biofeedback forms; employed when modulation of brain activity is the therapeutic target.

Clinical policy definition and scope

PurposeThis clinical policy provides a guide to medical necessity to assist in making coverage decisions and administering benefits.

Not a contractIt does not constitute a contract, guarantee of payment, or guarantee of results.

Provider responsibilityProviders must exercise professional medical judgment and are responsible for documentation and treatment decisions.

Coverage governanceCoverage decisions are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable law.