MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Biofeedback as a Treatment for Urinary Incontinence

Number 2.01.527*

Effective Date May 13, 2013

Revision Date(s) N/A

Replaces 2.01.27

*Medicare has a policy

Policy

Biofeedback therapy for urinary incontinence (UI) is considered medically necessary as part of a comprehensive outpatient treatment plan when ALL of the following criteria are met:

  • The urinary incontinence type is 1 or more of the following:
  • lower urinary tract dysfunction/voiding dysfunction
  • mixed
  • overflow
  • stress
  • urge

and

  • The individual has failed a 4-week trial of non-pharmacologic treatment such as bladder training or pelvic muscle training alone and
  • The individual is able to actively participate physically and cognitively in the therapy and
  • The therapy plan includes realistic individual goals that are clearly identified and are likely to be met within a predictable timeframe and
  • There is no neurological disease, pathology/uropathy of the urinary system and
  • Biofeedback therapy is delivered by a qualified provider. A qualified provider is one who is licensed and performs within the scope of his/her licensure or practice.

Biofeedback for urinary incontinence is considered not medically necessary if there is no measurable improvement after 8-weeks of therapy.

Biofeedback therapy for treatment of urinary incontinence is considered investigational for:

  • Unsupervised home use of biofeedback and biofeedback devices
  • Electroencephalography (EEG) biofeedback or neurofeedback.

Related Policies

1.01.17

Pelvic Floor Stimulation as a Treatment of Urinary Incontinence

2.01.28

Neurofeedback

2.01.29

Biofeedback as a Treatment for Headache

2.01.64

Biofeedback as a Treatment of Fecal Incontinence or Constipation

2.01.504

Biofeedback for Miscellaneous Indications

5.01.512

Botulinum Toxin

7.01.69

Sacral Nerve Neuromodulation/Stimulation

7.01.106

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

Policy Guidelines

Depending on the condition being treated, biofeedback sessions are usually scheduled 2 to 3 times per week for 6 to 8 weeks.

A typical program consists of 10 to 20 training sessions of 30 minutes each.

Response time can vary if there are existing comorbidities.

An individual who responds more quickly to treatment may require less biofeedback therapy.

Description

Urinary incontinent (UI) is a common condition defined as an involuntary leakage of urine. Women are twice as likely to be affected as men, and prevalence increases with age. The severity of incontinence affects quality of life and treatment decisions. The types of UI include stress, urge, overflow, functional post-prostatectomy incontinence, and voiding dysfunction and giggle incontinence in children. Nonsurgical treatment options may include pharmacologic treatment, pelvic muscle exercises (PME), bladder training exercises, biofeedback and electrical stimulation devices. Biofeedback is a nonsurgical treatment for urinary incontinence.

Biofeedback therapy is a training technique used by licensed specialty healthcare professionals to teach patients self-regulation of physiologic processes not generally considered to be under voluntary control. Sensors are placed on the body to monitor functions like breathing, heart rate, muscle tension, blood pressure and skin temperature changes. This biological information is fed back to the individual using visual, auditory or other evidence of certain bodily functions. With this heightened awareness of the targeted body functions the individual can learn to exert voluntary control. Biofeedback is a treatment for UI as well as constipation and migraine headaches has been supported by professional societies and evidence published in peer reviewed literature.

Biofeedback, in conjunction with pelvic floor muscle training (PFMT), is intended to enhance awareness of body functions so the patient can learn pelvic floor exercises for strengthening the muscles involved with the micturition reflex. There are several methods of biofeedback that may be employed for the treatment of UI, including vaginal cones or weights, perineometers, and electromyographic (EMG) systems with vaginal and rectal sensors. Animated biofeedback has been reported to as an effective modality used as a training tool to help manage dysfunctional voiding in children. (1)

Regulatory Status

A variety of biofeedback devices are cleared for marketing though the U. S. Food and Drug Administration’s (FDA) 510(k) process. The FDA defines a biofeedback device as “an instrument that provides a visual or auditory signal corresponding to the status of one or more of a patient's physiological parameters (e.g., brain alpha wave activity, muscle activity, skin temperature, etc.) so that the patient can control voluntarily these physiological parameters.”

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

Biofeedback and biofeedback devices are specifically excluded under many benefit plans.

Biofeedback and biofeedback devices are considered behavioral training and education/training in nature, and also specifically excluded under many benefit plans. (See Scope section)

Rationale

A TEC Assessment from 1995 on biofeedback for various indications noted there are several methodologic difficulties that arise in assessing biofeedback. (2) For example, most interventions that include biofeedback are multimodal and include relaxation and behavioral instruction, which may have effects separate from those that may occur due to biofeedback. While studies may report a beneficial effect of multimodality treatment, without appropriate control conditions, it is impossible to isolate the specific contribution of biofeedback to the overall treatment effect. For example, relaxation, attention, or suggestion may account for successful results that have been attributed to biofeedback. These effects are nonspecific therapeutic factors, some of which can be considered placebo effects. In order to demonstrate efficacy of biofeedback for treating incontinence, studies are therefore needed that isolate the effect of biofeedback and demonstrate an improvement in health outcomes compared to other interventions such as relaxation or behavioral therapy alone. In addition, although studies in the 1990s found that feedback on physiologic processes provided patients with an enhanced ability to control these processes, evidence is needed on the relationship between a patient’s ability to exert control over the targeted physiologic process and any health benefits of the intervention. The latter finding underscores the importance of seeking controlled studies showing whether use of biofeedback improves disease-related health outcomes, as opposed to physiologic, intermediate outcomes.

Women with Urinary Incontinence

In 2011, a Cochrane review was published evaluating feedback or biofeedback in conjunction with pelvic floor muscle training (PFMT) for treating urinary incontinence (UI) in women. (3) The review included randomized controlled trials (RCTs) in women with stress, urge or mixed UI in which at least 2 arms of the study included exercise training and at least one arm included feedback and/or biofeedback. Feedback was defined as verbal feedback by a clinician, whereas biofeedback involved use of an instrument or device. After examining 36 full-text articles, 24 trials were found to meet the review’s inclusion criteria and 17 contributed data to the analysis of at least one primary outcome measure. Sixteen of the 24 trials included a comparison of PFMT plus biofeedback to PFMT alone; 9 of these included the same PFMT programs in both groups. The primary outcomes of the review were quality-of-life and improvement or cure. Nine trials used one of several validated quality-of-life instruments; however, only 4 of these reported data in a form that could be used for meta-analysis. Thus, quality-of-life results were not pooled. Data were pooled for the other primary outcome, improvement or cure, but there were a sufficient number of studies only for the comparison between PFMT with and without biofeedback. In a pooled analysis of 7 studies, there was a significant reduction in the proportion of women reporting ‘no improvement or cure’ when biofeedback was added to muscle exercise (risk ratio [RR]: 0.75, confidence interval [CI]: 0.66 to 0.86). The authors noted that there may have been other differences between groups, such as more frequent contact with a healthcare professional or a greater number of treatment sessions, which might partially explain the difference in the improvement or cure rate in women who did or did not receive biofeedback. Moreover, when only the outcome ‘no cure’ was examined, there was not a significant difference between groups that did and did not receive biofeedback (5 studies: RR: 0.92, 95% CI: 0.81-1.05). Among secondary outcomes, a pooled analysis of 7 trials did not find a significant difference in leakage episodes in a 24-hour period after treatment (mean difference: -0.01, 95% CI: -0.21 to 0.01). For the outcomes frequency and nocturia, data could not be combined but the review authors reported that the pattern was one of no difference between groups.

As noted in the description of the Cochrane review, above, studies evaluating biofeedback for treating urinary incontinence (UI) in women have used various combinations of interventions and a variety of comparison interventions. Selected larger RCTs that compared PFMT with and without biofeedback (i.e., attempted to isolate the effect of biofeedback) and that were published as full articles are described below.

In 2003, Burgio and colleagues published a study reporting on findings of a RCT with 222 women who had urge or mixed incontinence. (4) Interventions in this 3-armed trial were as follows: 1) n=74 patients who received behavioral training along with digital palpation instruction (no biofeedback) and 4 office visits in 8 weeks; 2) n=73 patients who received biofeedback-assisted behavioral training and 4 office visits in 8 weeks; and 3) n=75 patients who were given a self-help book with no office visits (control condition). Behavioral training in the 2 intervention groups included teaching pelvic floor exercises, as well as skills and strategies for reducing incontinence. Patients in all groups kept bladder diaries through the 8-week treatment period. In an intention-to-treat analysis, the mean reduction in incontinence episodes was 69.4% in the behavioral training plus verbal feedback group, 63.1% in the behavioral training plus biofeedback group, and 58.6% in the control group. The 3 groups were not significantly different from one another (p=0.23). In addition, quality-of-life outcomes were similar in the 3 groups.

In 2006, Williams and colleagues in the U.K. published a study that included 238 women who had failed a primary behavioral therapy (e.g., advice on fluid intake, bladder re-education, and weight loss) for 3 months. (5) They were randomized to receive intensive PFMT (n=79), PFMT using vaginal cones (n=80) or continued behavioral therapy (n=79) for 3 months. Patients in all 3 groups were seen in the clinic every other week for 8 weeks and also at 12 weeks. At 12 weeks, all 3 groups had moderate reductions in incontinence episodes and some improvement in voiding frequency; there were no statistically significant differences in outcomes among the 3 groups. For example, mean reduction in incontinence episodes over 24 hours was -1.03 in the PFMT group, -0.28 in the vaginal cone group, and -0.59 in the control group (p=0.2).

Men with Post-prostatectomy Urinary Incontinence

In 2007, a systematic review of pelvic floor muscle training (PFMT) to improve UI after radical prostatectomy was published by MacDonald and colleagues. (6) The review identified 3 studies (281 men) that compared biofeedback and PFMT to muscle training alone (written/verbal instructions provided). Study findings were not pooled; none of the individual trials found a statistically significant difference in outcomes between groups.

Several more RCTs have been published since the MacDonald review. In 2012, Tienforti and colleagues in Italy compared biofeedback (a session before and after surgery) in combination with written/verbal instructions on performing pelvic floor muscle exercises to a control intervention of written/verbal instructions alone. (7) The study included 34 patients, 32 of whom (16 in each group) were available for the final 6-month analysis. By 6 months, 10 of 16 patients (62.5%) in the treatment group and 1 of 16 patients (6.3%) in the control group had achieved continence; this difference was statistically significant (p value not reported). The mean number of incontinence episodes per week was also significantly lower in the intervention group (2.7) than the control group (13.1) at 6 months.

Two trials have evaluated the combination of biofeedback and electrical stimulation in men with post-prostatectomy incontinence. (8, 9) (These studies are also discussed in a separate medical policy, see Related Policies). The trials had mixed findings. Mariotti et al. (2009) (7) found a beneficial effect of the combined intervention of biofeedback and electrical stimulation, whereas the Goode et al. (2011) (9) study did not find a benefit compared to behavioral therapy alone. Both studies were limited in that they did not isolate the effect of biofeedback, and thus the independent effect of biofeedback on outcomes cannot be determined. Trials are described briefly below:

In 2009, Mariotti and colleagues in Italy compared a program of pelvic floor electrical stimulation and electromyographic (EMG) biofeedback (2 sessions weekly for 6 weeks) to written/verbal instructions for pelvic muscle exercises. All 60 patients (30 per group) completed the study through the 6-month follow-up. The mean time to regain continence was significantly shorter in the treatment group (8.0 weeks) than the control group (13.9 weeks), p=0.003. The continence rate was significantly higher in the treatment group beginning at the 4-week visit and continuing through the 20-week visit at which time 29 of 30 (96.7%) in the treatment group and 18 of 30 (60%) in the control group were continent. The difference in the rate of continence was not statistically significantly different at the final, 6-month visit at which time 29 patients in the treatment group continued to be continent compared to 20 of 30 (66.7%) in the control group. In this study, the effect of biofeedback without electrical stimulation compared to written/verbal instructions to perform pelvic floor muscle exercises was not evaluated. (8)

In 2011, Goode and colleagues published the results of a randomized trial comparing behavioral therapy alone to behavioral therapy in combination with biofeedback and pelvic floor electrical stimulation. The trial included 208 men with UI persisting at least 1 year after radical prostatectomy. Men with pre-prostatectomy incontinence were excluded. Participants were randomized to 1 of 3 groups; 8 weeks of behavioral therapy (PFMT and bladder control exercises) (n=70), behavioral therapy plus biofeedback and electrical stimulation (n=70), and a delayed-treatment control group (n=68). The biofeedback and electrical stimulation intervention, called “behavior-plus,” consisted of in-office electrical stimulation with biofeedback using an anal probe and daily home pelvic floor electrical stimulation. After 8 weeks, patients in the 2 active treatment groups were given instructions for a maintenance program of pelvic floor exercises and fluid control and were followed up at 6 and 12 months. The primary efficacy outcome was reduction in the number of incontinent episodes at 8 weeks, as measured by a 7-day bladder diary. A total of 176 of 208 (85%) randomized men completed the 8 weeks of treatment. In an intention-to-treat analysis of the primary outcome, the mean reduction in incontinent episodes was 55% (28 to 13 episodes per week) in the behavioral therapy group, 51% (26 to 12 episodes per week) in the behavior-plus group, and 24% (25 to 20 episodes per week) in the control group. The overall difference between groups was statistically significant (p=0.001), but the behavior-plus intervention did not result in a significantly better outcome than behavioral therapy alone. Findings were similar on other outcomes. For example, at the end of 8 weeks, there was a significantly higher rate of complete continence in the active treatment groups (11 of 70, 16% in the behavior group and 12 of 70, 17% in the behavior-plus group) than the control group (4 of 68, 6%), but the group receiving biofeedback and electrical stimulation did not have a significantly higher continence rate than the group receiving behavioral therapy alone. (9)

Children with Urinary Tract Dysfunction Incontinence

In 2006 Barroso et al. reported on a study of 36 children in Brazil with lower urinary tract dysfunction (LUTD) who were treated with a combination of electrical stimulation for the urge syndrome and biofeedback for the voiding dysfunction. LUTD is classified as urge syndrome or urge urinary incontinence (UI) when there is a disturbance in the bladder-filling phase and as dysfunctional voiding when there is vesicoperineal dyscoordination (VPD) in the voiding phase. In all, 36 children who presented with symptoms of urinary urgency and/or daily incontinence completed the treatment and were prospectively evaluated. The mean (range) follow-up was 13.8 (4–24) months, and their mean age 7 (3–14) years, 17 children were aged <5 years. The children were divided into two groups: group 1, with urge syndrome treated with superficial parasacral electrical stimulation, and group 2, with voiding dysfunction, treated with biofeedback. The results of the study showed that in group 1, the mean (range) number of electrical stimulation sessions was 13.1 (4–20). Of the 19 children treated, 12 had a complete clinical improvement, six a significant improvement, and one a mild improvement. In group 2, the mean (range) number of biofeedback sessions was 6 (4–14). Of the 17 children treated, there was complete improvement of symptoms in 10, significant improvement in two and mild improvement in five. Six children who had no resolution of symptoms after biofeedback had salvage therapy with electrical stimulation, after which four had complete improvement of symptoms, and two a 90% and 40% improvement, respectively. Taking the two groups together, after treatment, four children developed isolated episodes of urinary tract infection. Of 21 children with nocturnal enuresis, bed-wetting continued in 13 (62%) after treatment.(citation) The authors conclude that in this small, short-term follow-up study, the nonpharmacological treatment of voiding dysfunction using biofeedback and treatment of urge syndrome by electrical stimulation was effective for treating LUTD in children. (10)

In 2008, Kaye and Palmer published an article evaluating the efficacy of biofeedback with and without animation in treating dysfunctional voiding and urinary symptoms. The comparison reported included 120 girls with urinary complaints and exhibited dysfunctional voiding on electromyography uroflow.  The authors noted their comparison included the last 60 cases of biofeedback using electromyography tracing alone (non-animated) were compared with the first 60 cases using the Urostym Pediflow program (animated). The evaluation of the 2 groups included improvement in post-void residual volume after treatment, and time to resolution of symptoms and dysfunctional voiding. Results reported included the following: Dysfunctional voiding resolved in 95% of patients in both groups. Post-void residual reduction was similar, namely from 35% to 9% of pre-void volume in the nonanimated group, and from 28% to 8% in the animated group. Children in the animated biofeedback group achieved success in significantly fewer sessions (3.6) than those undergoing nonanimated biofeedback (7.6, t test p <0.05). The authors concluded that in spite of their proved experience with nonanimated biofeedback systems and inexperience with an animated system, animated biofeedback systems yielded similar results in a significantly shorter time. According to the authors, animated and nonanimated biofeedback is efficacious in the treatment of dysfunctional voiding and its symptoms. (11)

In 2010, Palmer published an article with an overview of bladder control and pediatric voiding dysfunction. The author addresses biofeedback and concludes that biofeedback has been shown to be very effective in children to correct incontinence secondary to dysfunctional voiding. The author further states biofeedback is effective in treating giggle incontinence and to help resolve vesicoureteral reflux (12)

A 2011, Desantis et al. in Canada conducted a systematic review to discover if biofeedback is an effective method to treat children less than 18 years of age with dysfunctional elimination syndrome. They found 27 studies (1 RCT and 26 case-series) to analyze. The pooled estimate showed 83% (95% CI: 79%-86%) and 80% (95% CI: 76%-85%) improvement in UTI and daytime incontinence respectively. I (2) statistic showed "Low" (7%) and "High" (77%) heterogeneity across studies results for UTI and daytime incontinence. The only included RCT favored biofeedback over standard therapy (RR 1.4, 95% CI: 0.98-2.00) but this was not statistically significant. On analysis of all included studies there was also improvement in constipation (18%-100%), frequency (67%-100%), urgency (71%-88%) and VUR (21%-100%). PVR improvement ranged from 26 ml to 99 ml and Q (max) improvement was from 3.1 ml/s-4.7 ml/s. The authors concluded that based on this review, biofeedback is an effective, non-invasive method of treating dysfunctional elimination syndrome, and approximately 80% of children benefited from this treatment. However, most reports were of low level of evidence and studies of more solid design such as RCT should be conducted. (13)

In 2011 Kajabafzadeh and associates studied 80 children in Iran with dysfunctional elimination syndrome who were assigned to undergo animated biofeedback with pelvic floor muscle exercises and behavioral modification (group A, n=40) or conservation therapy (group B n=40) with behavioral modification only. (14) The authors’ results: Subjective and objective voiding problems were significantly improved. Vesicoureteral reflux resolved in 7 of 9 children (78%) and urinary tract infection did not recur in 10 of 14 children (71%) within 1 year. Bladder capacity and voided volume did not significantly improve. Post-void residual and voiding time decreased considerably, while maximum and average urine flow increased significantly. All children with fecal soiling and 17 of 25 with constipation (68%) in group A were symptom-free within 1 year after treatment. Animated biofeedback therapy was more efficient than nonbiofeedback management regarding objective and subjective voiding problems and bowel dysfunction (p <0.05). The study conclusions were that Animated biofeedback effectively treats bowel and voiding dysfunction in children with dysfunctional voiding. Pelvic floor muscle exercises coordinate breathing and pelvic floor muscle contractions, and are beneficial in improving bowel dysfunction.

Practice Guidelines and Position Statements

American Urological Association

In 2012, the American Urological Association (AUA) published a guideline to provide a clinical framework for the diagnosis and treatment of non-neurogenic overactive bladder. (15) The first-line treatments state:

  • Clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, and fluid management) as first line therapy to all patients with OAB. Standard (Evidence Strength Grade B)
  • Behavioral therapies may be combined with anti-muscarinic therapies. Recommendation (Evidence Strength Grade C)

Specific components of behavioral treatment can include self-monitoring (bladder diary), scheduled voiding, delayed voiding, double voiding, pelvic floor muscle training and exercise (including pelvic floor relaxation), active use of pelvic floor muscles for urethral occlusion and urge suppression (urge strategies), urge control techniques (distraction, self-assertions), normal voiding techniques biofeedback, electrical stimulation, fluid management, caffeine reduction, dietary changes (avoiding bladder irritants), weight loss and other life style changes

In 2007, the Agency for Healthcare Research and Quality (AHRQ) issued an Evidence Report/Technology Assessment, Prevention of Urinary and Fecal Incontinence in Adults, based on research conducted by the Minnesota Evidence-based Practice Center (EPC). (16,17). The report’s executive summary section titled “Effects of Clinical Interventions on UI”, includes the authors’ overview of the evidence on the clinical effectiveness of interventions including biofeedback for various UI conditions in adult females and males. The following are excerpts from the report that include biofeedback:

  • Clinical interventions for primary prevention of UI in pregnant women were examined in 8 large randomized controlled trials (RCTs) with more than 100 women and one smaller trial; pelvic floor muscle training with biofeedback and electrostimulation started at nine weeks after vaginal delivery resulted in continence 10 times more often compared to usual care at 10 months of follow-up.
  • Clinical interventions for primary prevention of UI in males with urological diseases were examined in 12 randomized controlled trials, 2 of 8 trials with continence outcomes, reported significant benefit after pelvic floor muscle training with biofeedback compared to usual care; the highest continence rate (99 percent) was reported in a large, well designed RCT of early pelvic floor muscle training and biofeedback in participants who had radical retropubic prostatectomy for localized prostate cancer at one year of follow-up with a small significant relative benefit compared to usual care; continence rates in the control groups were more than 60 percent across other RCTs with no statistically significant differences compared to active treatments. The comparative effectiveness of pelvic floor muscle training compared to usual care in males after different treatment options for prostate cancer requires future confirmation in well-designed RCTs.
  • Pelvic floor muscle training for secondary prevention of UI found weak evidence suggesting beneficial effects of behavioral interventions on UI in females; pelvic floor muscle training combined with biofeedback were sensitive in one small RCT with a 2-month follow-up.

In 2006, National Institute for Health and Clinical Excellence (NICE) issued a guideline on the management of urinary incontinence in women. NICE states that “perineometry or pelvic floor electromyography as biofeedback should not be used as a routine part of pelvic floor muscle training”, but that “electrical stimulation and/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation and adherence to therapy.” (18) The conclusion regarding use of biofeedback is based on expert opinion.

In 2012, the American Urogynecologic Society (AUGS) published empiric treatment recommendations (19) oriented to both urge and stress urinary incontinence as follows:

  • Lifestyle modification: smoking cessation, decrease excessive fluid intake, restrict bladder irritants (caffeine, carbonated beverages, and artificial sweeteners), weight reduction, regular bowel movement, adjust physical activity.
  • Pelvic floor muscle strengthening with (Kegel) exercises with or without biofeedback
  • Bladder retraining, urge suppression training, scheduled or prompted voiding
  • Treat severe atrophic vaginitis with tropical estrogen

Medicare National Coverage

This policy applies to biofeedback therapy rendered by a practitioner in an office or other facility setting. Biofeedback is covered for the treatment of stress and/or urge incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. (20) Biofeedback is not a treatment, per se, but a tool to help patients learn how to perform PME. Biofeedback-assisted PFMT incorporates the use of an electronic or mechanical device to relay visual and/or auditory evidence of pelvic floor muscle tone, in order to improve awareness of pelvic floor musculature and to assist patients in the performance of exercises. A failed trial of PFMT is defined as no clinically significant improvement in urinary incontinence after completing 4 weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength. Contractors may decide whether to cover biofeedback as an initial treatment modality. Home use of biofeedback therapy is not covered.

References

  1. Glazier DB, Ankem MK, Ferlise V, Gazi M, Barone JG. Utility of biofeedback for the daytime syndrome of urinary frequency and urgency of childhood. Urology. Apr 2001; 57(4):791-4.
  2. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Biofeedback. TEC Assessments 1995; Volume 10, Tab 25.
  3. Herderschee R, Hay-Smith EJ, Herbison GP et al. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev 2011; (7):CD009252.
  4. Burgio KL, Goode PS, Locher JL et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA 2002; 288(18):2293-9.
  5. Williams KS, Assassa RP, Gillies CL et al. A randomized controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed incontinence. BJU Int 2006; 98(5):1043-50.
  6. MacDonald R, Fink HA, Huckabay C et al. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int 2007; 100(1):76-81.
  7. Tienforti D, Sacco E, Marangi F et al. Efficacy of an assisted low-intensity programme of perioperative pelvic floor muscle training in improving the recovery of continence after radical prostatectomy: a randomized controlled trial. BJU Int 2012 [Epub ahead of print].
  8. Mariotti G, Sciarra A, Gentilucci A et al. Early recovery of urinary continence after radical prostatectomy using early pelvic floor electrical stimulation and biofeedback associated treatment. J Urol 2009; 181(4):1788-93.
  9. Goode PS, Burgio KL, Johnson TM, 2nd et al. Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial. JAMA 2011; 305(2):151-9.
  10. Barroso U, Lordelo P, Lopes AA, et al. Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneious electrical stimulation: a pilot study. BJU Int 2006; Jul; 98(1);166-171.
  11. Kaye JD, and Palmer LS. Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. J Urol. 2008 Jul; 180(1):300-5.
  12. Palmer LS. Biofeedback in the management of urinary continence in children. Curr Urol Rep. 2010 Mar; 11(2): 122-7.
  13. Desantis dj, Leonard MP, et al. Effectiveness of biofeedback for dysfunctional elimination syndrome in peadiatrics: a systematic review. J Pediatr Urol 2011 Jun; Vol. 7 (3). 342-8.
  14. Kajbafzadeh AM, Sharifi-Rad L, Ghahestani SM, Ahmadi H, Kajbafzadeh M, Mahboubi AH. Animated biofeedback: an ideal treatment for children with dysfunctional elimination syndrome. J Urol. Dec 2011;186(6):2379-84.
  15. Gormley EA, Lightner DJ, etal. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. 2012. Available at URL address: http://www.auanet.org/content/media/OAB_guideline.pdf. Last accessed April 22, 2013.
  16. Shamliyan TA, Kane RL, Wyman J et al. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008; 148(6):459-73.
  17. Shamiilyan T, Wyman J, Bliss DZ et al. Prevention of urinary and fecal incontinence in adults. AHRQ Publication No. 08-E003, 2007. Available at URL address: http://archive.ahrq.gov/clinic/epcarch.htm. Last accessed April 22, 2013.
  18. National Institute for Health and Clinical Excellence (NICE). Urinary incontinence: the management of urinary incontinence in women. 2006. Last accessed April 22, 2013.
  19. AUGS Statement on Pelvic Floor Rehabilitation. Position Statements. 2008. Available at URL address:http://www.augs.org/p/cm/ld/fid=202. Last accessed April 22, 2013.
  20. Centers for Medicare and Medicaid Services (CMS). National Coverage Decision (NCD) for biofeedback therapy for the treatment of urinary incontinence (30.1.1). Available at URL address: www.cms.hhs.gov. Last accessed April 22, 2013.
  21. Reviewed by practicing pediatrician,April 2013.
  22. BlueCross BlueShield Association Medical Policy Reference Manual, Biofeedback as a Treatment of Urinary Incontinence in Adults. Medical Policy Reference Manual, Policy No. 2.01.27, 2012.

Coding

Codes

Number

Description

CPT

90875

Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, behavior modifying or supportive psychotherapy); approximately 20-30 minutes

 

90876

Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, behavior modifying or supportive psychotherapy); approximately 45-50 minutes

 

90901

Biofeedback training by any modality

 

90911

Biofeedback training, perineal muscles, anorectal or urethral sphincter, including electromyography (EMG) and/or manometry

ICD-9 Procedure

89.21

Urinary manometry

 

89.23

Urethral sphincter electromyogram

 

93.08

Electromyography (EMG)

 

94.39

Other individual psychotherapy (biofeedback)

ICD-9 Diagnosis

   

ICD-10-CM
(effective 10/1/14)

   

ICD-10-PCS
(effective 10/1/14)

GZC9ZZZ

Biofeedback

HCPCS

E0746

Electromyography (EMG), biofeedback device

Type of Service

Medicine

 

Place of Service

Outpatient

Physician office

Home

 

Appendix

Definitions:

Voiding dysfunction – a general term to describe the condition where there is a lack of coordination between the bladder muscle (detrusor) and the urethra.

Urinary incontinence – is any involuntary leakage of urine, whether a large amount or just a few drops.

History

Date

Reason

02/11/13

NEW policy. PR policy was created to define biofeedback as medically necessary when criteria are met and not excluded by the member’s health plan contract. This is different from the BC policy 2.01.27 that states biofeedback for UI is investigational.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
©2013 Premera All Rights Reserved.