ModifiedPremera BluecrossPolicy 2.01.540

MEDICAL POLICY 2.01.540 Biofeedback for Incontinence

Defines medical necessity criteria, limitations, and billing codes for biofeedback treatment of urinary and fecal incontinence in adults and biofeedback for dysfunctional elimination syndrome in pediatric patients for Premera Blue Cross individual plans.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY 2.01.540 Biofeedback for Incontinence

Policy CodePolicy 2.01.540

Change TypePolicy statements revisedbackground removed

Effective DateJul 1, 2025

Next Review Date

Key ActionDocument failure of a trial of ordered pelvic muscle exercises (PME) for adults and ensure pediatric biofeedback is prescribed by a urologist and paired with pelvic muscle training.

SourceLink

POLICY UPDATE CHANGES

Policy statements updated for adult and pediatric individuals; Background section removed; Reference updated.

Removed CPTs 90875, 90876 and 90911; added 90912 and 90913 (historical change noted).

6/6moAdult session limit

10 lifetimePediatric session limit

>=5Pediatric minimum age covered

EMG not coveredDevice coverage

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Policy 2.01.540 (effective 07/01/2025, last reviewed 06/23/2025) addresses Biofeedback for Incontinence. The policy stance is covered with criteria for adults and pediatric patients. For adults (≥18 years) biofeedback for urinary and fecal incontinence/constipation is covered when specified medical necessity criteria are met; adult treatment is limited to up to six treatments per six months per condition. For pediatrics (ages 5 to <18 years) biofeedback for dysfunctional elimination syndrome is covered when specified criteria are met; pediatric treatment is limited to ten sessions per lifetime. The policy excludes coverage for an electromyography (EMG) biofeedback device.

Thresholds and Limits

Adult treatment limitUp to six treatments per six months per condition

Pediatric lifetime limitTreatment is limited to ten sessions per lifetime

Pediatric age minimumBiofeedback not covered for children under 5 years of age; pediatric eligibility begins at age 5

Device coverageNo coverage provided for the electromyography (EMG) biofeedback device

Session limits billing ruleLimit adult biofeedback to six treatments per six months per condition; pediatric biofeedback limited to ten sessions per lifetime

Medical Necessity Criteria

Medical Necessity - Adults (>= 18 years)

Biofeedback for urinary incontinence and fecal incontinence/constipation is considered medically necessary when ALL of the following criteria are met:

ALL of the following

Treatment is billed by a practitioner according to their scope of practice for a diagnosis of urinary incontinence or fecal incontinence/constipation
Constipation when the patient suffers from pelvic floor dyssynergia
Potential treatable problems should be identified and treatment implemented prior to biofeedback
The individual has failed a documented trial of an ordered plan of pelvic muscle exercises (PME) designed to increase periurethral muscle strength

Medical Necessity - Pediatric (ages 5 to <18 years)

Biofeedback for dysfunctional elimination syndrome is considered medically necessary when ALL of the following criteria are met:

ALL of the following

Patient is between 5 and 18 years of age
Patient is cognitively intact
Biofeedback must be prescribed by a urologist
Biofeedback must be performed in conjunction with pelvic muscle/floor training
ONE of the following bladder dysfunction conditions
- Bladder-sphincter dyssynergia

Not Covered, Exclusions, and Experimental Indications

Not Covered / Exclusions and Experimental

Specific settings, devices, populations, and indications that are not covered or considered experimental:

ALL of the following

Home use of biofeedback therapy is not covered
Biofeedback training in a group setting is not covered
No coverage provided for the electromyography (EMG) biofeedback device
Biofeedback therapy for encopresis or constipation in children is considered experimental and investigative
Biofeedback is not a treatment option for children under five years of age
Biofeedback therapy should not be used for signs that may indicate other physical problems (e.g., unusual straining, small/narrow stream, dripping; cloudy or pink urine; bloodstains on underwear or night clothes) — these will not be covered

Home use of biofeedback, group biofeedback sessions, use of EMG biofeedback devices, and biofeedback therapy for pediatric encopresis or constipation are specifically not covered. The policy history notes that the Background section was removed in the latest revision approved 06/23/2025.

Coding

Covered CPT CodesCPTCovered

90901	Biofeedback training by any modality
90912	Biofeedback training; perineal muscles, anorectal or urethral sphincter; including EMG and/or manometry, initial 15 minutes
90913	Biofeedback training; perineal muscles, anorectal or urethral sphincter; including EMG and/or manometry, each additional 15 minutes

Covered ICD-10 / Diagnosis Codes (if selection criteria are met)ICD-10Covered

G83.4	Cauda equina syndrome
K59.00-K59.09	Constipation
K59.4	Anal spasm
N31.	Neuromuscular dysfunction of bladder (flaccid neuropathic bladder; not elsewhere classified)
N31.9	Neuromuscular dysfunction of bladder, unspecified
N36.41	Intrinsic sphincter deficiency (ISD)
N36.42	Intrinsic sphincter deficiency (ISD)
N36.43	Post-void dribbling
N36.44	Muscular disorders of urethra
N36.8	Other specified disorders of urethra

1–10 of 28

1/3

Not Covered DevicemixedNot Covered

EMG device

Electromyography (EMG) biofeedback device — no coverage provided

Provider Actions & Billing Impact

Prior Authorization

Provider billing and scope requirement

Treatment must be billed by a practitioner according to their scope of practice; for pediatric biofeedback the service must be prescribed by a urologist.

Documentation Required

Document failed conservative therapy

Documented failure of a trial of ordered pelvic muscle exercises (PME) is required for adults prior to coverage; for pediatric recurrent UTI associated with dysfunctional elimination, physical causes must be ruled out and medications/conservative measures must have failed.

Billing Rule

Session limits

Limits on number of sessions apply.

90901
90912
90913
Adult: up to 6 treatments per 6 months per condition
Pediatric: limited to 10 sessions per lifetime

Denial Risk

Settings and device exclusions

Claims for home use, group sessions, EMG devices, or excluded pediatric indications will be denied.

Home use of biofeedback therapy is not covered
Biofeedback training in a group setting is not covered
No coverage provided for the electromyography (EMG) biofeedback device
Biofeedback therapy for encopresis or constipation in children is considered experimental and investigative
Biofeedback is not a treatment option for children under five years of age

Revision History

2025-06-23material_changeLatest

Annual review approved June 23, 2025; policy statements updated for adult and pediatric individuals; Background section removed; Reference updated.

2020-11-01historical_change

Annual review approved October 22, 2020: Removed CPTs 90875, 90876 and 90911; added 90912 and 90913.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY 2.01.540 Biofeedback for Incontinence

Policy CodePolicy 2.01.540

Change TypePolicy statements revisedbackground removed

Effective DateJul 1, 2025

Next Review Date

Key ActionDocument failure of a trial of ordered pelvic muscle exercises (PME) for adults and ensure pediatric biofeedback is prescribed by a urologist and paired with pelvic muscle training.

SourceLink

On This Page

OpenPayer

MEDICAL POLICY 2.01.540 Biofeedback for Incontinence

Coverage Summary

Medical Necessity Criteria

Not Covered, Exclusions, and Experimental Indications

Coding

Provider Actions & Billing Impact

Background

Revision History