I obtained a copy of a recent Position Statement from Blue Cross/Blue Shield that pertains to biofeedback and neurofeedback from a professional online neurofeedback user group. Unfortunately, Blue Cross/Blue Shield still considers neurofeedback “Investigational and Not Medically Necessary” for all conditions. It appears that Blue Cross/Blue Shield failed to include vital studies, some reviewed on this website, such as Gevensleben et al.’s (2009) ADHD research, Kouijzer et al.’s (2009) Autism research, and Hoedlmoser et al.’s (2008) sleep and memory research. A copy of the entire Position Statement is posted in this report.
As you can imagine, many biofeedback/neurofeedback practitioners expressed their unhappiness with this decision and cited various reasons why they disagree with Blue Cross/Blue Shield, including their failure to incorporate important studies in their review. They further called on their colleagues and professional organizations to petition these findings. Additionally, if I read the Blue Cross/Blue Shield Position Statement right, they state that biofeedback for migraine is an acceptable treatment. This would be a welcome finding if true.
Here is the Blue Cross/Blue Shield Position Statement in its entirety:
Subject: Biofeedback Therapy and Neurofeedback
Policy #: MED.00023 Current Effective Date: 04/22/2009
Status: Revised Last Review Date: 02/26/2009
Neurofeedback is a specific technique where the electroencephalogram (EEG) is used as the source of feedback information in order to modify brain activity.
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.
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 Martin, 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).” (Campbell, 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.
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)
E0746 Electromyography (EMG), biofeedback device
No specific code for EEG biofeedback (neurofeedback) device
Peer Reviewed Publications:
1.. Angelakis 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-Davis 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.. Michael 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, Thompson 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, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain. 2007; 128(1-2):111-127.
18.. Nestoriuc Y, Rief W, Martin 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, Murphy 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.. Scott 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.. Campbell 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.. Hayes Inc. Hayes Medical Technology Directory. Biofeedback for Headache and Chronic Musculoskeletal Pain. Lansdale, PA: Hayes, Inc.; November 3, 2004. Updated December 16, 2007.
5.. Hayes Inc. Hayes Medical Technology Directory. Biofeedback for the Treatment of Hypertension. Lansdale, PA: Hayes, 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.
Biofeedback-assisted Relaxation Therapy (BFRT)
Temporomandibular Joint Disorder
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available.
Status Date Action
Revised 02/26/2009 Medical Policy & Technology Assessment Committee (MPTAC) review. Revised subject of document to Biofeedback Therapy and Neurofeedback. Clarified position statement as follows: 1) Added “supervised” to the medically necessary statement and removed “when performed in an outpatient setting under the medical supervision of a qualified clinician, such as an adult or pediatric psychiatric or psychologist;” 2) Removed “thermal biofeedback or biofeedback-assisted relaxation therapy (BFRT)” from the investigational and not medically necessary statement, and added “unsupervised” to the home biofeedback device statement. Revised the description/scope, rationale, background/overview, and references. Removed the definition section.
Reviewed 10/01/2008 Updated coding section with 10/01/2008 ICD-9 changes.
Reviewed 02/21/2008 MPTAC review. Updated description, background, coding and references. The phrase “investigational/not medically necessary” was clarified to read “investigational and not medically necessary.” This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 03/08/2007 MPTAC review. Updated references.
Reviewed 03/23/2006 MPTAC review. Updated references.
11/17/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised 04/28/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations Last Review Date
Anthem, Inc. 04/27/2004
MED.00023 Biofeedback Therapy
WellPoint Health Networks, Inc. 12/02/2004
2.10.16 Biofeedback for Headache
It appears that those in the field of neurofeedback / biofeedback have their work cut-out for them in order to gain acceptance by major insurance companies.