CAM 20130

Biofeedback as a Treatment of Chronic Pain

Category:Medicine   Last Reviewed:April 2021
Department(s):Medical Affairs   Next Review:April 2022
Original Date:April 1998    

Description:
Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not normally considered to be under voluntary control. Electromyography biofeedback has been evaluated as a method to reduce chronic or recurrent pain of musculoskeletal or psychosomatic origin.

For individuals who have chronic pain (including low back, knee, neck and shoulder, orofacial, and abdominal pain as well as fibromyalgia, osteoarthritis, systemic lupus erythematosus, and vulvar vestibulitis) who receive biofeedback, the evidence includes multiple randomized controlled trials (RCTs) for different pain syndromes. The relevant outcomes are symptoms, functional outcomes, quality of life, and medication use. The results of these RCTs, some of which were sham-controlled, did not consistently report a benefit for biofeedback. Some RCTs reported improved outcomes with biofeedback, but these improvements were often of uncertain clinical significance or were not durable. Many other RCTs have found that biofeedback did not provide a significantly greater benefit in outcomes when it was used instead of or in addition to other conservative interventions such as exercise. Overall, the available RCTs were limited by small sample sizes and high dropout rates. This evidence base does not permit conclusions about the specific effects of biofeedback beyond the nonspecific effects of sham interventions, nor does it permit conclusions about the contribution of biofeedback beyond that of other conservative treatments for pain. The evidence is insufficient to determine the effects of the technology on health outcomes.   

Background
Treatment for chronic pain is often multimodal and typically includes psychological therapy. Psychological techniques vary but may include cognitive therapy, which teaches subjects the ability to cope with stressful stimuli by attempting to alter negative thought patterns and dysfunctional attitudes, and behavioral approaches to reduce muscle tension and break the pain cycle. Relaxation, using any of a variety of techniques including meditation or mental imagery, is considered a behavioral therapy that may be used alone or as a component of a cognitive-behavioral therapy program. Electromyography biofeedback has also been used for the treatment of chronic pain, on the assumption that the ability to reduce muscle tension will be improved through the feedback of data to the patient regarding the degree of muscle tension. While some consider electromyography biofeedback to be a method used to obtain relaxation, others consider biofeedback to be distinct from other relaxation techniques. 

Regulatory Status
Since 1976, a large number of biofeedback devices have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process. Food and Drug Administration product code: HCC.

Related Policies
20127 Biofeedback as a Treatment of Urinary Incontinence in Adults
20128 Neurofeedback
20129 Biofeedback as a Treatment of Headache
20153 Biofeedback for Miscellaneous Indications
20164 Biofeedback as a Treatment of Fecal Incontinence or Constipation

Policy:
Biofeedback as a treatment of chronic pain, including, but not limited to, low back pain, is investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.  

Benefit Application
BlueCard®/National Account Issues
In many Plans, biofeedback is contractually excluded. If contractually excluded in the host Plan, but not in the home Plan, the host Plan may use this policy as the basis of coverage decisions for the home Plan.

Biofeedback may be offered as part of a comprehensive program in pain management as offered by pain management centers.

Rationale
The evidence review was created in April 1998 and has been updated regularly with searches of the PubMed database. The most recent literature update was performed through September 21, 2020.

Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life (QOL), and ability to function including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, 2 domains are examined: the relevance and quality and credibility. To be relevant, studies must represent 1 or more intended clinical uses of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Psychological treatments involve both nonspecific and specific therapeutic effects. Nonspecific effects (sometimes called placebo effects ) occur as a result of contact with the therapist, positive expectations on the part of the patient and therapist, and other beneficial effects that occur as a result of the patient being in a therapeutic environment. Specific effects are those that occur only because of the active treatment, beyond any nonspecific effects that may be present. This literature review focuses on identifying evidence that the effects of biofeedback are distinct from nonspecific placebo effects. Because establishing an ideal placebo control is problematic with psychological treatments and because treatment of chronic pain is typically multimodal, isolating the specific contribution of biofeedback is challenging.

Biofeedback
Clinical Context and Therapy Purpose
The purpose of electromyography (EMG) biofeedback in patients who have chronic pain is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does the use of EMG biofeedback improve the net health outcome in those who suffer from chronic pain?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with chronic pain, including low back, knee, neck and shoulder, orofacial, and abdominal pain as well as fibromyalgia, osteoarthritis, systemic lupus erythematosus, and vulvar vestibulitis.

Interventions
The therapy being considered is EMG biofeedback. Biofeedback provides physiologic information not normally available to the patient, with a concerted effort employed by the patient to use this feedback to help alter the physiologic process in some specific way. Biofeedback may be administered, using different techniques and monitoring devices and sensors (e.g., electromyograph), in an outpatient setting by psychiatrists, psychologists, and general practitioners. Biofeedback training is done either in individual or group sessions, alone or in combination with other behavioral therapies designed to teach relaxation. A typical program consists of 10 to 20 training sessions of 30 minutes each. Sessions can take up to 90 minutes. Training sessions are performed in a quiet, nonstimulating environment. Patients are instructed to use mental imagery techniques to affect the physiologic variable being monitored, and feedback is provided for the successful alteration of that physiologic parameter in the form of lights or tone, verbal praise, or other auditory or visual stimuli.

Comparators
The following therapies are currently being used to treat chronic pain: pharmacologic and nonpharmacologic therapy. For chronic pain management, a multimodal, multidisciplinary approach that is individualized to the patient is recommended.1, A multimodal approach to pain management consists of using treatments (i.e., nonpharmacologic and pharmacologic) from 1 or more clinical disciplines incorporated into an overall treatment plan. This allows for different avenues to address the pain condition, often enabling a synergistic approach that impacts various aspects of pain, including functionality. The efficacy of such a coordinated, integrated approach has been documented to reduce pain severity, improve mood and overall quality of life, and increase function.

Outcomes
The general outcomes of interest are reductions in symptoms and medication usage and improvements in functional outcomes.

The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommends that chronic pain trials should consider assessing outcomes representing 6 core domains: pain, physical functioning, emotional functioning, participant ratings of improvement and satisfaction with treatment, symptoms and adverse events, and participant disposition.2 Table 1 summarizes provisional benchmarks for interpreting changes in chronic pain clinical trial outcome measures per IMMPACT.3 

Table 1. Benchmarks for Interpreting Changes in Chronic Pain Outcome Measures 

Outcome Domain and Measure Type of Improvement Change
Pain intensity
0 to 10 numeric rating scale
Minimally important
Moderately important
Substantial
10 to 20% decrease
≥30% decrease
≥50% decrease
Physical functioning
Multidimensional Pain Inventory Interference Scale

Brief Pain Inventory Interference Scale

Clinically important

Minimally important

≥0.6 point decrease

1 point decrease
Emotional functioning
Beck Depression Inventory
Profile of Mood States
Total Mood Disturbance
Specific Subscales

Clinically important

Clinically important
Clinically important

≥5 point decrease

≥10 to 15 point decrease
≥2 to 12 point change
Global Rating of Improvement
Patient Global Impression of Change
Minimally important
Moderately important
Substantial
Minimally improved
Much improved
Very much improved

Study Selection Criteria 
Methodologically credible studies were selected using the following principles:  

  • To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.

  • Studies with larger sample sizes were preferred.

Review of Evidence
General Chronic Pain
Several meta-analyses have reviewed RCTs assessing psychological therapies for a variety of nonheadache chronic pain conditions. A Cochrane review by Williams et al. (2020) focused on chronic pain in adults. 4 Two RCTs were identified that compared behavioral therapy with an active control designed to change behavior (i.e., exercise or instruction). Three RCTs had sufficient follow-up to be included in a comparison of behavioral therapy and usual treatment. Reviewers found no evidence that behavioral therapy had any effect on pain compared to active control or usual treatment. Additionally, there was no evidence of a difference between behavioral therapy and active control or usual treatment in terms of disability at the end of treatment.

Another Cochrane review by Fisher et al. (2018) focused on children and adolescents with chronic and recurrent pain. 5 Although psychological therapies were found to improve pain, only 1 study evaluated biofeedback in nonheadache pain. Biofeedback did not improve abdominal pain more than cognitive-behavioral therapy (CBT) in this trial (by Humphreys and Gevirtz [2000]6; see the section on Abdominal Pain). Palermo et al. (2010) published a meta-analysis of studies on psychological therapies for the management of chronic pain in children and adolescents.7 These authors did not identify any additional RCTs on biofeedback for managing nonheadache pain.

Low Back Pain
Systematic Reviews
A Cochrane review by Henschke et al. (2010) assessed behavioral treatments for chronic low back pain and conducted a meta-analysis of 3 small randomized trials that compared EMG biofeedback with a waiting-list control group.8 In the pooled analysis, there were a total of 34 patients in the intervention group and 30 patients in the control group. The standardized mean difference (SMD) in short-term pain was -0.80 (95% confidence interval [CI], -1.32 to -0.28); this difference was statistically significant favoring the biofeedback group. Reviewers did not conduct meta-analyses of trials comparing biofeedback with sham biofeedback and therefore were unable to control for any nonspecific effects of treatment.

Randomized Controlled Trials
At least 1 RCT has compared biofeedback with a sham intervention for the treatment of low back pain. Kapitza et al. (2010) compared the efficacy of respiratory biofeedback with sham biofeedback in 42 patients with low back pain.9 Both groups showed a reduction in pain levels on a 10-point visual analog scale (VAS) at the end of the intervention period and at 3-month follow-up. Between-group differences were not statistically significant. For example, 3 months after the intervention, mean change in pain with activity decreased by 1.12 points in the intervention group and 0.96 points in the sham control group (p>0.05); mean change in pain at rest decreased by 0.79 points in the intervention group and 0.49 points in the control group (p>0.05).

Several trials with active comparison groups have not found that biofeedback is superior to alternative treatments. More recently, Tan et al. (2015) evaluated 3 self-hypnosis interventions and included EMG biofeedback as a control intervention.10 This RCT enrolled 100 patients with chronic low back pain. After the 8-week intervention, reported reductions in pain intensity were significantly higher in the combined hypnosis groups than in the biofeedback group (p=0.042).

A trial published by Glombiewski et al. (2010) assessed whether the addition of EMG biofeedback to CBT improved outcomes in 128 patients with low back pain.11 Patients were randomized to 1 of 3 groups: CBT, CBT plus biofeedback, or waiting-list control. Both treatments improved outcomes including pain intensity compared with the waiting-list control (moderate effect size of 0.66 for pain intensity in the CBT plus biofeedback group). However, the addition of biofeedback did not improve outcomes over CBT alone.

Chronic Knee Pain
Collins et al. (2012) conducted a systematic review and meta-analysis of RCTs on nonsurgical interventions for anterior knee pain.12 In a pooled analysis of data from 2 trials, there was no significant benefit of adding EMG biofeedback to an exercise-only intervention at 8 to 12 weeks (SMD=-0.22; 95% CI, -0.65 to 0.20).

Chronic Neck and Shoulder Pain
Ma et al. (2011) in Hong Kong published an RCT that included 72 patients with chronic (at least 3 months) computer work-related neck and shoulder pain.13 Patients were randomized to 1 of 4, 6-week interventions: biofeedback, exercise, passive treatment (e.g., hot packs), or a control group receiving only an educational pamphlet. The mean VAS score postintervention was 1.87 in the biofeedback group and 2.10 in the exercise group (p<0.05). Although this trial found a short-term benefit of a biofeedback intervention, the magnitude of difference in the VAS and Neck Disability Index scores was small and of uncertain clinical significance. In addition, there were several methodologic limitations. The trial had a small sample size and had a substantial number of dropouts. The intensity of the interventions was unbalanced; e.g., the biofeedback intervention was more intensive (2 h/d) than other interventions (e.g., passive treatment), which received 2, 15-minute sessions per week. Long-term data were not available due to the low rate of follow-up; at 6 months, data were available on only 39 (54%) of 72 participants, which was too small for meaningful analysis.

Ribeiro and Silva (2019) published an RCT assessing whether visual feedback improves range of motion in patients with chronic idiopathic neck pain.14 Forty-two patients from a single Portuguese clinic were included in the study and randomly assigned to either the visual feedback group (n=21) or the control group (n=21). There was no effect of time and intervention on pain intensity (p=0.729) , but there was a significant interaction between time and intervention in neck flexion (p<0.001). The study was limited by its small sample size, short duration of intervention, and by the researcher assessing patients not being blinded.

Orofacial Pain
A Cochrane review by Aggarwal et al. (2011) identified 17 trials evaluating nonpharmacologic psychological interventions for adults with chronic orofacial pain (e.g., temporomandibular joint disorder).15 For studies reporting on short-term pain relief (≤3 months), a significantly greater reduction in pain was found for interventions that combined CBT plus biofeedback compared with usual care (2 studies; SMD=0.46; 95% CI, 0.02 to 0.90). However, when reviewers assessed results from studies reporting on long-term pain relief (≥6 months), no significant benefit was found with a combined intervention of CBT plus biofeedback, and there were no studies that compared CBT alone with CBT plus biofeedback. For studies reporting on biofeedback-only interventions, a pooled analysis of 2 studies on short-term pain relief did not find a significant benefit compared with usual care (SMD=-0.41; 95% CI, -1.06 to 0.25). Only 1 study reported long-term pain relief after a biofeedback-only intervention, so a pooled analysis could not be done. Reviewers concluded that there was weak evidence to support psychosocial interventions for managing chronic orofacial pain and the most promising evidence was for CBT, with or without biofeedback. The authors noted that the trials comprising the review were few in number and had a high-risk of bias.

The conclusions drawn from this Cochrane review are similar to those of earlier systematic reviews on the treatment of temporomandibular joint disorder.16,17 These older reviews also concluded that there was weak evidence that psychosocial/physical therapy interventions (including biofeedback) are beneficial for treating temporomandibular joint disorder and that, of the few studies available, they tended to be of poor methodologic quality.

Abdominal Pain
Systematic Reviews
In a systematic review of therapies for recurrent abdominal pain in children by Weydert et al. (2003), the behavioral interventions of CBT and biofeedback had a generally positive effect on nonspecific recurrent abdominal pain and were deemed safe.18 The specific effects of biofeedback were not isolated in this systematic review and therefore cannot be assessed.

Randomized Controlled Trials
In a study by Humphreys and Gevirtz (2000), 64 children and teenagers diagnosed with recurrent abdominal pain were randomized to groups treated with increased dietary fiber; fiber and biofeedback; fiber, biofeedback, and CBT; or fiber, biofeedback, CBT, and parental support.6 The similar nature of the 3 multicomponent treatment groups was associated with greater pain reduction than the fiber-only group. This trial did not address placebo effects.

Fibromyalgia
Systematic Reviews
Glombiewski et al. (2013) published a systemic review and meta-analysis of RCTs reporting data on the efficacy of EMG and electroencephalography (EEG) biofeedback (i.e., neurofeedback) for treating patients with fibromyalgia.19 Reviewers identified 7 RCTs that compared biofeedback with a control method in patients with fibromyalgia. Studies in which biofeedback was evaluated only as part of multicomponent interventions were excluded. Three studies used EEG biofeedback and 4 used EMG biofeedback ( N=321 patients). A sham intervention was used as a control condition in 4 studies, 2 using EEG biofeedback and 2 using EMG biofeedback. In a pooled analysis of the studies using EMG biofeedback, a significant reduction in pain intensity was found compared with a different intervention (effect size, Hedges g=0.86; 95% CI, 0.11 to 0.62). A pooled analysis of studies on EEG biofeedback did not find a significant benefit in pain reduction compared with control methods. Pooled analyses of studies of EMG and EEG biofeedback did not find a significant benefit of either intervention on other outcomes such as sleep problems, depression, and health-related QOL. None of the studies reviewed were of high quality, with the risk of bias assessed as unclear or high for all included studies. In addition, all studies reported short-term outcomes, resulting in a lack of evidence on whether longer-term outcomes improved with these interventions. (For more information on EEG biofeedback, see evidence review 2.01.28.)

Randomized Controlled Trials
In a small, double-blind RCT from Asia, Babu et al. (2007) compared actual and sham biofeedback for effects on pain, fitness, function, and tender points in 30 patients with fibromyalgia.20 Pain reduction, as assessed on a VAS, did not differ significantly between groups. The trialists calculated that a sample size of 15 patients could detect a difference of 5 cm (on a 10-cm scale) on a VAS, suggesting that the trial lacked adequate power.

A larger unblinded RCT by van Santen et al. (2002) evaluated 143 women with fibromyalgia, and compared EMG biofeedback with fitness training and with usual care.21 The primary outcome was pain measured on a VAS. Compared with usual care, the investigators reported no clear improvements in objective or subjective patient outcomes with biofeedback (or fitness training).

Another RCT on EMG biofeedback for fibromyalgia was conducted by Buckelew et al. (1998), and enrolled 119 patients; however, the trial did not follow a double-blind design.22 Patients were randomized to 1 of 4 treatment groups: (1) biofeedback/relaxation training, (2) exercise training, (3) combination treatment, and (4) an educational/attention control program. While the combination treatment group had better tender point index scores than other treatment groups, this trial did not address placebo effects or the impact of adding biofeedback to relaxation therapy.

Osteoarthritis
A systematic review by Macfarlane et al. (2012) evaluated practitioner-based complementary and alternative medicine treatments (defined as any treatment not taken orally or applied topically) for osteoarthritis and identified 2 trials on biofeedback.23 One was an RCT by Yilmaz et al. (2010) that assessed whether the addition of EMG biofeedback to strengthening exercises improved outcomes in 40 patients with knee osteoarthritis.24 After a 3-week treatment period, no significant differences between the 2 treatments regarding pain or QOL were found. The other RCT, by Durmus et al. (2007), compared electrical stimulation with biofeedback-assisted exercise in 50 women with knee osteoarthritis.25 After 4 weeks of treatment, there were no statistically significant differences between groups in pain and functioning scores.

Systemic Lupus Erythematosus
In an RCT by Greco et al. (2004), of 92 patients with systemic lupus erythematosus, those treated with 6 sessions of biofeedback-assisted CBT for stress reduction had statistically greater reductions in pain posttreatment than a symptom-monitoring support group (p=0.044) and a group receiving usual care (p=0.028).26 However, these reductions in pain were not sustained at a 9-month follow-up.

Vulvar Vestibulitis
A randomized study by Bergeron et al. (2001) of 78 patients with dyspareunia resulting from vulvar vestibulitis compared treatment with EMG biofeedback, surgery, or CBT.27 Patients who underwent surgery had significantly lower pain scores than patients who received biofeedback or CBT. No placebo treatment was used.

Summary of Evidence
For individuals who have chronic pain (including low back, knee, neck, and shoulder, orofacial, and abdominal pain as well as fibromyalgia, osteoarthritis, systemic lupus erythematosus, and vulvar vestibulitis) who receive biofeedback, the evidence includes multiple RCTs for different pain syndromes. Relevant outcomes are symptoms, functional outcomes, QOL, and medication use. The results of these RCTs, some of which were sham-controlled, did not consistently report a benefit for biofeedback. Some RCTs reported improved outcomes with biofeedback, but these improvements were often of uncertain clinical significance or were not durable. Many other RCTs have found that biofeedback did not provide a significantly greater benefit in outcomes when it was used instead of or in addition to other conservative interventions such as exercise. Overall, the available RCTs were limited by small sample sizes and high dropout rates. This evidence base does not permit conclusions about the specific effects of biofeedback beyond the nonspecific effects of sham interventions, nor does it permit conclusions about the contribution of biofeedback beyond that of other conservative treatments for pain. The evidence is insufficient to determine the effects of the technology on health outcomes.

Practice Guidelines and Position Statements
American College of Physicians
In 2017, the American College of Physicians issued practice guidelines on noninvasive treatments for acute, subacute, and chronic low back pain.28 For patients with chronic low back pain, the guidelines recommended that initial treatment should be nonpharmacologic, such as "exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavior therapy or spinal manipulation" (strong recommendation).

American College of Occupational and Environmental Medicine
In 2020, the American College of Occupational and Environmental Medicine updated their guideline on noninvasive and minimally invasive management of low back disorders.29 The role of biofeedback is not addressed in this updated guideline.

American Society of Anesthesiologists & American Society of Regional Anesthesia and Pain Medicine
In 2010, the practice guidelines from the American Society of Anesthesiologists and the American Society of Regional Anesthesia and Pain Medicine suggested that " cognitive behavioral therapy, biofeedback, or relaxation training....may be used as part of a multimodal strategy for patients with low back pain, as well as for other chronic pain conditions."30

U.S. Department of Veterans Affairs and U.S. Department of Defense
In 2020, the U.S. Department of Veterans Affairs and U.S. Department of Defense published a guideline on the diagnosis and treatment of low back pain.31 The guideline recommends several nonpharmacologic therapies for chronic low back pain (e.g., CBT and/or mindfulness-based stress reduction, progressive relaxation, exercise including yoga, pilates, and tai chi) but does not address the role of biofeedback.

North American Spine Society
In 2020, the North American Spine Society published a guideline for the diagnosis and treatment of low back pain.32 Although nonpharmacologic therapies are addressed in this guideline, the specific role of biofeedback for low back pain is not addressed.

U.S. Preventive Services Task Force Recommendations
Not applicable.

Ongoing and Unpublished Clinical Trials
Current ongoing and unpublished clinical trials that might influence this review are listed in Table 2.

Table 2. Summary of Key Trials  

NCT No. Trial Name Planned Enrollment Completion Date
Ongoing      
NCT02426476 HRV Biofeedback in Pain Patients: Pilot Intervention for pain, Fatigue, and Sleep 80 Sep 2020
NCT04197284 Comparison of Efficacy of Biofeedback, Electrical Stimulation and Therapeutic Exercise in Patients With Knee Osteoarthritis 93 Jun 2022

NCT: national clinical trial.

References 

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  33. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Biofeedback Therapy (30.1). n.d.; https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=41&ncdver=1&bc=AAAAQAAAAAAA&. Accessed September 22, 2020.

Coding Section

Codes Number Description
CPT 90875-90876 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  sychotherapy); code range
  90901 Biofeedback training by any modality
ICD-9 Procedure 94.39 Other individual psychotherapy (includes biofeedback)
ICD-9 Diagnosis   Investigational for all codes
HCPCS E0746 Electromyography (EMG), biofeedback device
ICD-10-CM (effective 10/01/15)   Investigational for all codes
  G56.40-G56.42 Causalgia of upper limb code range
  G57.70-G57.72 Causalgia of lower limb code range
  G89.0-G89.4 Pain, not elsewhere classified code range
  G90.50-G90.59 Complex regional pain syndrome I code range
  M25.50-M25.579 Pain in joint code range
  M54.00-M54.9 Dorsalgia code range
  M79.60-M79.676 Pain in limb, hand, foot, fingers and toes code range
  R52 Pain, unspecified
ICD-10-PCS (effective 10/01/15)   ICD-10-PCS codes are only for use on inpatient services.
  GZC9ZZZ Mental health, none, other biofeedback
Type of Service Medicine  
Place of Service Physician Office  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

04/01/2021 

Annual review, no change to policy intent. Updating background, rationale and references. 

04/01/2020 

Annual review, no change to policy intent. Updating description, regulatory status, rationale and references. 

04/01/2019 

Annual review, no change to policy intent. Updating rationale and references. 

04/18/2018 

Annual review, no change to policy intent. Updating rationale and references. 

04/03/2017 

Annual review, no change to policy intent. 

04/07/2016 

Annual review, no change to policy intent. Updated background, description, rationale and references. 

04/16/2015 

Annual review, no change to policy intent. Updated background, description, rationale, references. Added coding and regulatory status.

04/09/2014

Annual review. Updated related policies, benefit application, rationale and references. No change to policy intent.


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