CurrentFidelis CarePolicy CP.MP.168

Biofeedback

Defines medical necessity criteria for coverage of biofeedback therapy across specified indications (urinary incontinence, dysfunctional voiding in children, fecal incontinence, chronic constipation with dyssynergic defecation, tension/migraine headaches, chronic pain, and muscle re-education/spasticity-related abnormalities), and states that biofeedback for other indications is insufficiently supported.

Policy Summary

PayerFidelis Care

PolicyBiofeedback

Policy CodePolicy CP.MP.168

Change TypeCoding and criteria clarifications

Effective Date

Next Review Date

Key ActionDocument a four week trial of pelvic muscle exercise training for adult urinary incontinence prior to authorization.

SourceLink

POLICY UPDATE CHANGES

Removed CPT 90911 and replaced with CPT 90912 and 90913.

Reworded criteria for clarity over multiple review cycles (e.g., removing gender-specific verbiage, removing rigid session limits, consolidating criteria language).

Clarified constipation indication to specify dyssynergic defecation.

Administrative cross-reference added to refer behavioral health biofeedback to CP.BH.300.

7Covered Indications Listed

1Referenced CPT code group

2Material changes in this revision

Coverage Summary

Scope: Defines medical necessity criteria for coverage of biofeedback therapy across specified indications including urinary incontinence, dysfunctional voiding in children, fecal incontinence, chronic constipation with dyssynergic defecation, tension/migraine headaches, chronic pain, and muscle re-education/spasticity-related abnormalities.

Overview: Biofeedback therapy provides visual, auditory, or other feedback of physiological functions to enable voluntary control and is commonly used as an adjunct to pelvic floor muscle exercises for urinary incontinence and for other specific indications listed in the policy. The policy references professional society guidance from the American Gastroenterological Association (AGA) and the American Society of Colon and Rectal Surgeons (ASCRS).

Coverage stance: mixed.

Medical-Necessity Criteria

Documentation Required

Document trial of pelvic muscle exercises for urinary incontinence

For adult urinary incontinence prior to authorizing biofeedback, document that the patient completed and failed a trial of pelvic muscle exercise training lasting four weeks. Include this explicitly in the clinical record (treatment start/end dates, frequency/intensity of exercises, response) to demonstrate the required four week trial.

Not Supported / Insufficient Evidence

Not supported / Insufficient evidence

Biofeedback is considered not supported when the indication is not one of those specified above:

There is insufficient evidence to support the safety and efficacy of biofeedback for any other conditions than those specified in the medically necessary section

Coding

Covered CPT (informational codes referenced)CPT

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 (List separately in addition to code for primary procedure).

2020 CPT coding update: Removed CPT 90911 (deleted 1/1/2020) and replaced with CPT 90912 and 90913. This change is noted in the policy's coding/revision history and coding implications.

Provider Actions / Documentation Requirements

Documentation Required

Document trial of pelvic muscle exercises for urinary incontinence

For adult urinary incontinence, document a four week trial of pelvic muscle exercise training prior to biofeedback authorization. Records should note the duration (four weeks), the pelvic muscle exercise regimen used, dates of the trial, and evidence of failure to improve after that four week period.

Required duration: four week trial
Document start and end dates of the four week trial
Document regimen and frequency of pelvic muscle exercises
Document lack of adequate clinical improvement after four weeks

Documentation Required

Document prior conservative therapies for pediatric dysfunctional voiding

Background and Evidence

Background: Biofeedback uses devices to provide visual, auditory or other evidence of physiological functions so individuals can learn voluntary control to alleviate abnormal conditions. It is used as an adjunct to pelvic floor muscle exercises for urinary incontinence to improve ability to perform exercises and has evidence of benefit when added to pelvic floor training. Biofeedback is also used in pediatric dysfunctional voiding after failure of conservative therapies, for fecal incontinence and chronic constipation (including training to relax the pelvic floor in dyssynergic defecation), for certain headaches, chronic pain, and for muscle re-education in spasticity or weakness. Professional society guidance referenced includes the AGA recommendations supporting biofeedback for defecatory disorders and the ASCRS guidance that biofeedback may be considered for fecal incontinence.

Source	Key Point
Cochrane review (urinary incontinence)	Systematic review/meta-analysis of 17 trials found better outcomes when biofeedback added to pelvic floor exercises
American Gastroenterological Association (AGA)	Recommends pelvic floor retraining by biofeedback rather than laxatives for defecatory disorders (strong recommendation, high-quality evidence); instrumented anorectal biofeedback recommended to manage symptoms in defecatory disorders (strong recommendation, moderate-quality evidence).
ASCRS 2023	2023 guidelines: biofeedback may be considered for fecal incontinence (conditional recommendation; quality of evidence: low); noninvasive option for patients not responding to conservative measures with reported 64%–89% improvement in nonrandomized studies.

Definition: Biofeedback therapy — Therapy providing visual, auditory or other evidence of body functions (e.g., heart rate, skin temperature, muscle tone) allowing voluntary control to alleviate abnormal conditions.

Medicare Determinations

Number	Name	Type	Effective Date
30.1	Biofeedback therapy	NCD
30.1.1	Biofeedback therapy for the treatment of urinary incontinence	NCD	2001-07-01

Revision History

04/20revised

Removed CPT 90911 (deleted 1/1/2020) and replaced with CPT 90912 and 90913.

05/20revised

Removed I.B.5 'Anal muscle abnormalities of spasticity, incapacitating muscle spasm, and/or muscle weakness' as duplicative; revised language in I.B.3 and added contraindications to I.B.3.b.

05/21revised

Replaced 'experimental/investigational' language in II with statement that there is insufficient evidence to draw conclusions regarding efficacy for circumstances other than those specified; replaced 'member' with 'member/enrollee.'

Documentation Required

Fecal incontinence diagnostic documentation

For fecal incontinence, document diagnostic testing findings and absence of contraindications prior to biofeedback. Specifically, include anorectal manometry results demonstrating either external anal sphincter weakness or decreased ability to perceive rectal distension due to nerve injury. Also document that none of the listed contraindications are present (isolated internal anal sphincter weakness; overflow incontinence associated with behavioral or psychiatric disorders; neurological disorders with substantial loss of rectal sensation and/or inability to contract the external anal sphincter; decreased rectal storage capacity from resection, inflammation, or fibrosis; or suspected/established major structural damage to continence mechanisms).

Anorectal manometry showing external anal sphincter weakness OR decreased perception of rectal distension (nerve injury)
Document absence of contraindications: isolated internal anal sphincter weakness; overflow incontinence with behavioral/psychiatric disorders; neurological disorders causing substantial loss of rectal sensation or inability to contract external sphincter; decreased rectal storage capacity from resection/inflammation/fibrosis; suspected or established major structural damage to continence mechanisms