HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
Y-20-010
Topic:
Biofeedback
Section:
Therapy
Effective Date:
January 1, 2020
Issued Date:
October 4, 2021
Last Revision Date:
September 2021
Annual Review:
September 2021
 
 

Biofeedback is a technique intended to teach individuals self-regulation of certain physiologic processes not normally considered to be under voluntary control.

Policy Position

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 is capable of participating in the treatment plan (physically and cognitively).

 

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

90875

90876

90901

90912

90913

A9279

E0746


Functional Constipation Rome IV Diagnostic Criteria

  • Must include two or more of the following:
    • Straining during at least 25% of defecations; or
    • Lumpy or hard stools in at least 25% of defecations; or
    • Sensation of incomplete evacuation for at least 25% of defecations; or
    • Sensation of anorectal obstruction/blockage for at least 25% of defecations; or
    • Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor); or
    • 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.

Related Policies

Refer to Medical Policy Y-12, Urinary Incontinence Therapy, for additional information.


Covered Diagnosis Codes


F40.01

F41.0 

G43.001

G43.009

G43.011

G43.019

G43.101

G43.109

G43.111

G43.119

G43.401

G43.409

G43.411

G43.419

G43.501

G43.509

G43.511

G43.519

G43.701

G43.709

G43.711

G43.719

G43.801

G43.809

G43.811

G43.819

G43.901

G43.909

G43.911

G43.919

G44.201

G44.209

G44.211

G44.219

G44.221

G44.229

K59.00

K59.01

K59.02

K59.03

K59.04

K59.09

N39.3

N39.41

N39.46

N39.491

N39.492

R15.0

R15.1

R15.2

R15.9

R32

 

 

 

 


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 co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.