TRANSMITTAL #:  129

DATE:  12/23/2011

TRICARE CHANGE #:  N/A

CHAMPVA POLICY MANUAL

CHAPTER: 2

SECTION: 30.5

TITLE: BIOFEEDBACK

AUTHORITY:  38 CFR 17.270(a) and 17.272(a)

RELATED AUTHORITY:   32 CFR 199.4(e)(17)

I. EFFECTIVE DATE(S)

February 6, 1989

II. PROCEDURE CODE(S)

A.      CPT Codes: 90875-90876, 90901, and 90911

B.      HCPCS Level II Code E0746

III. DESCRIPTION(S)

A.      Biofeedback therapy is a technique by which a person is taught to exercise control over a physiologic process occurring within the body.  By using modern biomedical instruments the patient learns how a specific physiologic system within his body operates and how to modify the performance of this particular system.

IV. POLICY

A.      Services and supplies are covered in connection with electrothermal, electromyography and electrodermal biofeedback therapy when there is documentation that the patient has undergone an appropriate medical evaluation, that their present condition is not responding to or no longer responds to other forms of conventional treatment, the patient is referred by a physician, and the therapy is rendered by an authorized provider.  The following conditions are authorized:

B.      Adjunctive treatment for Raynaud's Syndrome.

C.      Adjunctive treatment for muscle re education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, or incapacitating muscle spasm or weakness.  

D.      Biofeedback treatment is limited to a maximum of 20 combined inpatient and outpatient biofeedback treatments per calendar year.  Treatments denied are not to be counted as part of the 20 allowed biofeedback treatment per calendar year.

E.       Payable benefits include the initial intake evaluation (CPT 90901).  This initial evaluation is not to be included in the maximum yearly treatment limits.

V. EXCLUSION(S)

A.      Biofeedback for hypertension.

B.      Biofeedback for the treatment of migraine headaches.

C.      Biofeedback therapy provided for the treatment of ordinary muscle tension.  

D.      Rental or purchase of biofeedback equipment.  

E.       Treatment of psychosomatic conditions, such as psychophysiological or psychological factors affecting medical conditions.  This exclusion includes individual psychophysiological therapy incorporating biofeedback training.

*END OF POLICY*