CurrentCentenePolicy CP.BH.300

Biofeedback for Behavioral Health Disorders

Defines Centene's medical necessity criteria, limits, and documentation expectations for behavioral health–related biofeedback for members with anxiety disorders or post-traumatic stress disorder; applies to Centene Advanced Behavioral Health and affiliated health plans.

Policy Summary

PayerCentene

PolicyBiofeedback for Behavioral Health Disorders

Policy CodePolicy CP.BH.300

Change TypeClarified continuation reviewadded neurosound/biosound exclusionprogress metric updated

Effective Date

Next Review Date

Key ActionObtain prior authorization: up to 25 initial biofeedback sessions authorized if all criteria met; additional sessions reviewed case-by-case by a Medical Director with documented 25% improvement since last review.

SourceLink

POLICY UPDATE CHANGES

Added criteria point V. to indicate insufficient scientific evidence to support the efficacy of neurosound/biosound treatment.

Clarified that up to 25 initial sessions are medically necessary when criteria met and up to an additional 20 continuation sessions will be reviewed case-by-case by a Medical Director.

Changed continuation progress metric from comparison to baseline to comparison to the last review (25% reduction).

25initial covered biofeedback sessions

20additional continuation sessions

25%progress threshold (review)

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Coverage Criteria for Biofeedback (Behavioral Health)

Initial Therapy

Covered when ALL of the following are met

Initial Therapy Criteria: A. The member/enrollee has a DSM V-TR diagnosis of anxiety disorder or post-traumatic stress disorder (PTSD).; B. There are significant symptoms that interfere with functioning in at least one life area as measured by a widely recognized validated standardized severity scale focused on the symptom profile.; C. The member/enrollee is motivated to and can actively participate in the treatment plan, including being responsive to care plan requirements (e.g., practice and follow-through at home).; D. A comprehensive treatment plan includes biofeedback as an adjunctive intervention in addition to other primary evidence-based interventions.; E. The condition can be appropriately treated with biofeedback (e.g., existing pathology does not prevent success of the treatment).; F. There is evidence that standard evidence-based outpatient treatments (including psychotherapy and medication management) are considered insufficient to treat the member/enrollee's condition safely and effectively.; G. There is a readily identifiable response measurable by a symptom-specific validated standardized scale.; H. Biofeedback training is performed by a physician or qualified non-physician practitioner who has undergone biofeedback training and certification (may include nurse practitioners, physician assistants, qualified mental health professionals, psychologists, and where applicable, biofeedback technicians).; I. A treatment plan is individualized with clearly stated realistic goals and objectives.; J. Treatment is structured to achieve optimum benefit and expected benefit is documented.; K. There is a documented planned transition out of biofeedback from the start of treatment (may include ensuring the member can continue techniques independently after sessions end).

All items A-K must be met

Continuation Therapy

Continuation covered when ALL of the following are met and reviewed by a Medical Director

Continuation Criteria: A. The initial criteria remain met.; B. The frequency of sessions is scheduled at a rate consistent with the presenting symptoms and is showing results (a lower rate may impede progress).; C. Progress related to biofeedback can be clearly described by at least a 25% reduction in severity compared to the last review.; D. When medically necessary, appropriate psychopharmacological intervention is provided.; E. There is a documented planned transition out of biofeedback from the start of treatment, which includes: 1) a plan ensuring the member can continue biofeedback-learned techniques independently after sessions end; and 2) a goal with a clear and reasonable score range on a validated scale assessment demonstrating meaningful progress from the treatment.>=25% improvement

Case-by-case Medical Director review required

Discharge / End of Medical Necessity

Discontinue when ANY of the following are met

Discharge Criteria: A. The documented goals and objectives have been achieved.; B. The member/enrollee no longer meets initiation or continuation criteria, or symptom severity has dropped by 50%.; C. The member/enrollee is not engaging in treatment, rendering biofeedback ineffective, despite multiple documented attempts to address non-participation.; D. The member/enrollee refuses treatment.; E. The member/enrollee is not making progress toward treatment goals and there is no reasonable expectation of progress with this treatment approach.; F. Continuing improvement is reasonably predicted with ongoing psychotherapy, medication management and/or community support.>=50% reduction for B

Any one item suffices for discharge

The policy specifies that biofeedback is considered medically necessary only for anxiety disorders and post‑traumatic stress disorder (PTSD) when the documented criteria are met. There is insufficient evidence in the published peer‑reviewed literature to support use of biofeedback for any other behavioral health diagnosis, and such uses are not supported by this policy.

The policy further states that neurosound/biosound treatments — often billed under neurofeedback CPT codes — lack sufficient scientific evidence in the published peer‑reviewed literature to support their use for behavioral health conditions; therefore these modalities are not supported by this policy for behavioral health diagnoses outside the specified indications.

Coding and Progress Thresholds

Referenced CPT CodesCPT

90901	Biofeedback training by any modality.
90875	30 minutes of individual psychophysiological therapy incorporating biofeedback training
90876	45 minutes of individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy

inv-07: Progress improvement threshold

Progress improvement threshold>= 25% reduction in severity compared to the last review

Measurement basisCompared to the last documented clinical review (not baseline)

Required for continuation authorizationDemonstrated at least once during Medical Director case-by-case review to permit additional sessions

inv-08: Discharge symptom reduction threshold

Discharge symptom reduction threshold>= 50% reduction in severity

Use for discontinuationIf symptom severity has dropped by 50% the member no longer meets initiation/continuation criteria and discharge is appropriate

Provider Actions, Authorization, and Documentation

Documentation Required

Adjunctive Use Requirement

Biofeedback must be provided as an adjunctive intervention and included in a comprehensive treatment plan that incorporates primary evidence-based treatments (e.g., psychotherapy and/or medication management). The treatment plan must be individualized with realistic goals and objectives, document a planned transition out of biofeedback from the start of treatment (including ensuring ability to continue learned techniques independently), and demonstrate that standard evidence‑based outpatient treatments alone are insufficient to treat the condition safely and effectively.

Adjunctive use: Biofeedback must be adjunctive to primary evidence-based interventions (e.g., psychotherapy, medication management).
Individualized treatment plan: clearly stated realistic goals and objectives; expected benefit and structure to achieve optimum benefit documented.
Planned transition: documented plan from treatment start to ensure independent continuation of learned techniques after sessions end.
Provider qualifications: performed by a physician or qualified non-physician practitioner who has undergone biofeedback training and certification (e.g., nurse practitioner, physician assistant, psychologist, qualified mental health professional, or biofeedback technician where applicable).

Background

Biofeedback is a therapeutic technique that provides real‑time monitoring of physiological functions (for example, brainwaves, heart rate variability, respiration, muscle tension, and skin temperature) and uses that information to teach voluntary self‑regulation skills. When applied in behavioral health, biofeedback is intended as an adjunct to evidence‑based treatments (such as psychotherapy and medication management) and is delivered by trained clinicians as part of an individualized treatment plan with measurable goals.

Definitions

inv-14: Definition of Biofeedback

DefinitionBiofeedback is a therapeutic technique that uses instruments to monitor physiological activity and provide real-time feedback to facilitate voluntary control of specific physiological functions.

Physiological signalsMay include brainwaves, heart rate, respiration, muscle tension, and skin temperature

Clinical purposeTeaches self-regulation skills to support improved health and behavioral outcomes

Level of Care Criteria

Treatment Modalities

Biofeedback / Neurofeedback

Modality Use: Biofeedback modalities include heart rate variability (HRV) biofeedback, neurofeedback, respiration/muscle tension/skin temperature monitoring; modalities should be adjunctive to psychotherapy and/or medication management and delivered by trained clinicians; some modalities (e.g., neurosound/biosound) lack sufficient evidence and are not supported by peer-reviewed literature.

Modalities must be appropriate to condition and delivered by qualified personnel

Visit Limits

inv-17: biofeedback sessions — initial visit limit (25)

Initial visit/session limitUp to 25 initial behavioral health-related biofeedback sessions are medically necessary if all initiation criteria are met.

Applies toMembers with DSM V-TR anxiety disorder or PTSD meeting all initial criteria

Documentation requiredIndividualized treatment plan, goals, validated severity scale baseline and planned transition must be documented

inv-18: additional biofeedback sessions — continuation additional sessions (20) reviewed case-by-case

Additional continuation sessionsUp to an additional 20 continuation sessions will be reviewed on a case-by-case basis by a Medical Director.

Continuation requirements

Revision History

2024-06-24added_criteria

Added criteria point V. stating there is insufficient evidence to support neurosound/biosound treatment for behavioral health disorders.

2023-07-23clarified_continuation_and_progress_metricLatest

Clarified continuation language to state 'up to an additional 20 sessions' will be reviewed and changed the progress metric wording to compare improvement to the last review rather than baseline; added detail to II.E about transition plan and a measurable goal on a validated scale.