Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Procedures

  Biofeedback for constipation in adults may be considered medically necessary for individuals with dyssynergia-type constipation as demonstrated by meeting ALL of the following criteria:

• Symptoms of functional constipation that meet ROME IV criteria; and
• Objective physiologic evidence of pelvic floor dyssynergia demonstrated by inappropriate contraction of the pelvic floor muscles or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging, or electromyography (EMG); and
• Failed a three (3) month trial of standard treatments for constipation including laxatives, dietary changes, and exercises (as many of the previous as are tolerated).

Biofeedback may be considered medically necessary as part of the overall treatment plan for migraine and tension-type headache. Before a biofeedback program is introduced, a physician must determine that the headaches are not pathological in nature. Such pathologies include:

• Brain tumors; or
• Hematoma; or
• Edema; or
• Aneurysm; or
• Disease of the eyes, ears, or sinus.

Biofeedback may be considered medically necessary for the treatment of stress and/or urge incontinence in cognitively intact individuals who have failed a documented trial of pelvic muscle exercise (PME) training. A failed trial is defined as no clinically significant improvement in urinary continence after completing four (4) weeks of an ordered regimen of PMEs.

Biofeedback using capnometry guided respiratory intervention (CGRI) (e.g., Freespira) may be considered medically necessary as part of the overall treatment plan for adult individuals (age 18 and older) diagnosed with panic disorder and/or posttraumatic stress disorder (PTSD) when the individual can participate in the treatment plan (physically and cognitively).

Biofeedback, not meeting the criteria as indicated in this policy is considered experimental/investigational, and therefore noncovered because the safety and efficacy cannot be established by the review of the available published peer-reviewed literature.

    Functional constipation ROME IV diagnostic criteria

• Must include two or more of the following:

            o   Straining during at least 25% of defecations; or

            o   Lumpy or hard stools in at least 25% of defecations; or

            o   Sensation of incomplete evacuation for at least 25% of defecations; or

            o   Sensation of anorectal obstruction/blockage for at least 25% of defecations; or

            o   Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor); or

            o   Fewer than three defecations per week; and

• Loose stools are rarely present without the use of laxatives; and
• Insufficient criteria for irritable bowel syndrome.

*Criteria fulfilled for the last three (3) months with symptom onset at least six (6) months prior to diagnosis.

    Post-payment audit statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

    Place of service: inpatient/outpatient

Experimental/investigational (E/I) services are not covered regardless of place of service.

Biofeedback is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a comorbid condition that would require monitoring in a more controlled environment such as the inpatient setting.