Blue Cross Position Statement on Biofeedback

[Guest guest]

I am wishing for all of you who want to pursue this to be covered by your

insurance. I advise you all to get your MDs and PCPs on board with the plans

and goals, this may be very helpful to you, and to pursue appeals to the 3rd

degree, when more than 2/3 of denied claims are indeed approved.

BUT in the meantime, read this carefully as many insurance companies do follow

Blue Cross Policies very carefully. This is the position statement from 2009.

Subject: Biofeedback Therapy and Neurofeedback

Policy #: MED.00023 Current Effective Date: 04/22/2009

Status: Revised Last Review Date: 02/26/2009

Description/Scope

Neurofeedback is a specific technique where the electroencephalogram (EEG) is

used as the source of feedback information in order to modify brain activity.

Position Statement

Investigational and Not Medically Necessary:

Electroencephalogram (EEG) biofeedback, also known as neurofeedback, is

considered investigational and not medically necessary for all conditions.

The use of unsupervised home biofeedback devices is considered investigational

and not medically necessary for all conditions.

Rationale

Results of randomized controlled trials of individuals with migraine or tension

headaches have shown that biofeedback is associated with a decrease in the

headache pain and use of less migraine medication compared to individuals

treated with self-relaxation therapy alone (Nestoriuc and , 2007;

Nestoriuc, 2008).

The American Academy of Family Physicians (AAFP) 2000 guidelines on preventive

therapy for migraines, based on evidence review by the U.S. Headache Consortium,

recommend that " relaxation training, thermal biofeedback combined with

relaxation training, EMG biofeedback and cognitive-behavioral therapy may be

considered as treatment options for prevention of migraine (Grade A

recommendation). " (, 2000; Morey, 2000)

The National Institute of Neurologic Disorders and Stroke (NINDS) states that

" when headaches occur three or more times a month, preventive treatment is

usually recommended. Drug therapy, biofeedback training, stress reduction, and

elimination of certain foods from the diet are the most common methods of

preventing and controlling migraine and other vascular headaches. Drug therapy

for migraine is often combined with biofeedback and relaxation training. "

(NINDS, 2008)

At this time there is insufficient or conflicting evidence in the peer-reviewed

literature comparing biofeedback to established treatment modalities (e.g.

pharmacotherapy or behavior therapy), to conclude that biofeedback therapies or

neurofeedback (i.e. EEG biofeedback) are effective treatments for other

conditions, including, but not limited to, anxiety disorders, asthma, attention

deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD)

(Drechsler, 2007; Leins, 2007), cardiovascular disease, constipation,

endometriosis-associated pain, hypertension (Nakao, 2003; Rainforth, 2007),

insomnia, learning disabilities, menopausal hot flashes, movement disorders,

Raynaud's syndrome (Middaugh, 2001), seizure disorders, or substance

abuse-related disorders.

Biofeedback medical devices are classified by the U.S. Food and Drug

Administration (FDA) as Class II, special controls, medical devices, subject to

certain limitations and exempt from 510(k) pre-market notification. Despite the

availability of numerous biofeedback devices for home use, biofeedback has not

been adequately studied in unsupervised home settings.

Background/Overview

Neurofeedback (i.e. EEG biofeedback) describes the feedback of neural

information and has been investigated as a treatment of a variety of disorders

including ADHD, anxiety and panic disorders, depression, learning disabilities,

menopausal hot flashes, seizure disorders, sleep disorders, stress management,

substance abuse and related disorders, or traumatic brain injury. Although

related in concept to biofeedback, neurofeedback differs in that the information

fed back to the individual (i.e. EEG tracings) is a direct measure of global

neuronal activity, while other biofeedback technique provide feedback on

specific physiological processes such as tension of specified muscle groups or

skin temperature. The individual may be trained to either increase or decrease

the prevalence, amplitude or frequency of specified EEG waveforms (e.g., alpha,

beta, theta waves), depending on the changes in brain function associated with

the particular disorder.

90901 Biofeedback training by any modality

When services are Investigational and Not Medically Necessary:

For the procedure codes listed above, for all other diagnoses not listed, or

when the code describes a procedure indicated in the Position Statement section

as investigational and not medically necessary.

When services are also Investigational and Not Medically Necessary:

CPT 90911 Biofeedback training, perineal muscles, anorectal or urethral

sphincter, including EMG and/or manometry

No specific code for EEG biofeedback (neurofeedback)

HCPCS

E0746 Electromyography (EMG), biofeedback device

No specific code for EEG biofeedback (neurofeedback) device

ICD-9 Diagnosis

All diagnoses

References

Peer Reviewed Publications:

1.. kis E, Stathopoulou S, Frymiare JL, et al. EEG neurofeedback: a brief

overview and an example of peak alpha frequency training for cognitive

enhancement in the elderly. Clin Neuropsychol. 2007; 21(1):110-129.

2.. Benner- S, Heaton PC. Attention deficit and hyperactivity disorder:

controversies of diagnosis and safety of pharmacological and nonpharmacological

treatment. Curr Drug Saf. 2007; 2(1):33-42.

3.. Drechsler R, Straub M, Doehnert M, et al. Controlled evaluation of a

neurofeedback training of slow cortical potentials in children with attention

deficit/hyperactivity disorder (ADHD). Behav Brain Funct. 2007; 26:33-35.

4.. Egner, T, Gruzelier, J.H. EEG biofeedback of low beta band components:

frequency-specific effects on variables of attention and event-related brain

potentials. Clinical Neurophysiology. 2004; 115:131-139.

5.. Gardea M, Gatchel R, Mishra K. Long-term efficacy of biobehavioral treatment

of temporomandibular disorders. 2001; 24(4):341-359.

6.. Grego D. Management of adolescent chronic pelvic pain for endometriosis: a

pain center perspective. Journal Pediatric Adolescent Gynecology. 2003;

16:217-219.

7.. Hammond DC. Neurofeedback with anxiety and affective disorders. Child

Adolesc Psychiatric Clin N Am. 2005; 14:105-123.

8.. Holtmann M, Stadler C. Electroencephalographic biofeedback for the treatment

of attention-deficit hyperactivity disorder in childhood and adolescence. Expert

Rev Neurother. 2006; 6(4):533-540.

9.. Lake EA. Behavioral and nonpharmacological treatments of headache. Headache.

2001; 85(4):1055-1075.

10.. Leins U, Goth G, Hinterberger T, et al. Neurofeedback for children with

ADHD: a comparison of SCP and Theta/Beta protocols. Appl Psychophysiol

Biofeedback. 2007; 32(2):73-88.

11.. Levesque J, Beauregard M, Mensour B. Effect of neurofeedback training on

the neural substrates of selective attention in children with

attention-deficit/hyperactivity disorder: a functional magnetic resonance

imaging study. Neurosci Lett. 2006; 394(3):216-221.

12.. Meuret A, Wilhelm F, Roth W. Respiratory feedback for treating panic

disorder. J Clinical Psychol. 2004; 60 (2):197-207.

13.. AJ, Krishnaswamy S, Mohamed J. An open label study of the use of

EEG biofeedback using beta training to reduce anxiety for patients with cardiac

events. Neuropsychiatr Dis Treat. 2005; 1(4):357-363.

14.. Middaugh SJ, Haythornthwaite JA, B, et al. The Raynaud's Treatment

Study: biofeedback protocols and acquisition of temperature biofeedback skills.

Appl Psychophysiol Biofeedback. 2001; 26(4):251-278.

15.. Monastra VJ. Quantitative electroencephalography and

attention-deficit/hyperactivity disorder: implications for clinical practice.

Curr Psychiatry Rep. 2008; 10(5):432-438.

16.. Nakao M, Yano E, Nomura S, Kuboki T. Blood pressure-lowering effects of

biofeedback treatment in hypertension: a meta-analysis of randomized controlled

trials. Hypertens Res. 2003; 26(1):37-46.

17.. Nestoriuc Y, A. Efficacy of biofeedback for migraine: a

meta-analysis. Pain. 2007; 128(1-2):111-127.

18.. Nestoriuc Y, Rief W, A. Meta-analysis of biofeedback for

tension-type headache: efficacy, specificity, and treatment moderators. J

Consult Clin Psychol. 2008; 76(3):379-396.

19.. Proctor ML, PA, Pattison HM, et al. Behavioural interventions for

primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2007;

(3):CD002248.

20.. Rainforth MV, Schneider RH, Nidich SI, et al. Stress reduction programs in

patients with elevated blood pressure: a systematic review and meta-analysis.

Curr Hypertens Rep. 2007; 9(6):520-528.

21.. Scharff L, Marcus DA, Masek BJ. A controlled study of minimal-contact

thermal biofeedback treatment in children with migraine. J Pediatr Psychol.

2002; 27(2):109-119.

22.. Morey, S. Practice guidelines of the American Academy of Family

Physicians. Guidelines on migraine: part 4. General principles of preventive

therapy. Am Fam Physician. 2004; 62(1):2359-2360, 2363.

23.. Siepmann M, Aykac V, Unterdörfer J, et al. A pilot study on the effects of

heart rate variability biofeedback in patients with depression and in healthy

subjects. Appl Psychophysiol Biofeedback. 2008; 33(4):195-201

24.. Sierpina V, Astin J, Giordano J. Mind-body therapies for headache. Am Fam

Physician. 2007; 76(10):1518-1522.

25.. Silver N. Headache (chronic tension-type). Am Fam Physician. 2007;

76(1):114-116.

26.. Trautmann E, Lackschewitz H, Kröner-Herwig B. Psychological treatment of

recurrent headache in children and adolescents-a meta-analysis. Cephalalgia.

2006; 26:1411-1426.

27.. Vasudeva S, Claggett AL, Tietjen GE, McGrady AV. Biofeedback-assisted

relaxation in migraine headache: relationship to cerebral blood flow velocity in

the middle cerebral artery. Headache. 2003; 43(3):245-250.

Government Agency, Medical Society, and Other Authoritative Publications:

1.. Applied Psychology and Biofeedback. Disorders that are amenable to

intervention by biofeedback and neurofeedback. 2008. Available at:

http://www.aapb.org/. Accessed on January 9, 2009.

2.. JK, Penzien DB, Wall EM. Evidenced-based guidelines for migraine

headache: Behavioral and physical treatments. U.S. Headache Consortium 2000.

Available at: http://www.aan.com/professionals/practice/pdfs/gl0089.pdf.

Accessed on January 9, 2009.

3.. Centers for Medicare and Medicaid Services (CMS). National Coverage

Determination: Biofeedback. NCD #30.1 Effective date not posted. Available at:

http://www.cms.hhs.gov. Accessed on January 9, 2009.

4.. Inc. Medical Technology Directory. Biofeedback for Headache and

Chronic Musculoskeletal Pain. Lansdale, PA: , Inc.; November 3, 2004.

Updated December 16, 2007.

5.. Inc. Medical Technology Directory. Biofeedback for the Treatment

of Hypertension. Lansdale, PA: , Inc.; February 27, 2006. Updated March 3,

2008.

6.. National Institute of Neurologic Disorders and Stroke (NINDS). Headache

information page. December 11, 2008. Available at:

http://www.ninds.nih.gov/disorders/headache/headache.htm. Accessed on January

12, 2009.

7.. Silberstein, SD. Practice parameter: Evidence-based guidelines for migraine

headache (an evidence-based review): Report of the Quality Standards

Subcommittee of the American Academy of Neurology. Neurology. 2000; 55:754-762.

8.. U.S. Food and Drug Administration 510(k) Premarket Notification Database.

Information on releasable 510(k) Biofeedback Devices. Available at:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/search/search.cfm. Accessed on

January 9, 2009.

Index

Biofeedback-assisted Relaxation Therapy (BFRT)

BrainMasterTM

EEG Biofeedback

Neurofeedback

ProComp-2T

Temporomandibular Joint Disorder

Thermal Biofeedback