Medical Policy


Subject: Biofeedback and Neurofeedback
Document #: MED.00125 Publish Date:    12/12/2018
Status: Reviewed Last Review Date:    11/08/2018


This document addresses biofeedback, a treatment method where an individual is given information, via an electronic monitor, about physiological processes that are normally involuntary, such as blood pressure, muscle tension, heart rate, and other bodily functions. The individual then uses this information to gain voluntary control and modify those processes. Examples of biofeedback techniques include thermal biofeedback, where the individual is provided information on skin temperature, and electromyographic (EMG) biofeedback, where the individual is provided information on muscle tension.

Neurofeedback (also known as EEG biofeedback) is a type of biofeedback that uses electroencephalograms (EEGs) as the feedback source. EEG information is signaled to the individual, usually by video or sound, for the purpose of training the individual to self-regulate brain activity. Neurofeedback is being studied for a variety of medical and psychological conditions.

Note: Neurofeedback (EEG biofeedback) should not be confused with electroencephalograms (EEGs) used for the diagnosis of neurological disorders.

Note: Biofeedback therapy is also addressed in the following documents:

Position Statement

Medically Necessary:

Biofeedback therapy supervised by a physician or licensed practitioner is considered medically necessary for the following conditions:

  1. Migraine or tension headaches; and
  2. Urinary incontinence; and
  3. Chronic constipation; and
  4. Fecal incontinence; and
  5. Levator ani syndrome, also known as anorectal pain syndrome; and
  6. Chronic back pain as part of a rehabilitation program; and
  7. Cancer pain.

Investigational and Not Medically Necessary:

Biofeedback therapy is considered investigational and not medically necessary for all other conditions.

Neurofeedback, also known as electroencephalogram (EEG) biofeedback, is considered investigational and not medically necessary for all conditions including, but not limited to: asthma, attention deficit – hyperactivity disorder, autistic spectrum disorders, cardiovascular conditions, cluster headaches, epilepsy, post-traumatic stress disorder, substance use disorders, and traumatic brain injury.

The use of home biofeedback devices is considered investigational and not medically necessary for all conditions.


Biofeedback for Migraine and Tension Headaches

Systematic reviews and the results of randomized controlled trials of individuals with migraine or tension headaches have shown that biofeedback is associated with a decrease in headache pain and less use of migraine medication compared to individuals, both adults and children, treated with self-relaxation therapy alone (Nestoriuc and Martin, 2007; Nestoriuc, 2008; Palermo, 2010; Scharff, 2002; Stubberud, 2016; Trautmann, 2006; Vasudeva, 2003).

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 American Academy of Neurology’s (Silberstein/AAN, 2009) recommendations for the evaluation and treatment of migraine headaches state that behavioral and physical interventions are used for preventing migraine episodes rather than for alleviating symptoms once an attack has begun. Although these modalities may be effective as monotherapy, they are more commonly used in conjunction with pharmacologic management. Relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy may be considered treatment options for prevention of migraine.

The National Institute of Neurologic Disorders and Stroke (NINDS, 2018) states that “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.”

Biofeedback for Urinary Incontinence

The evidence for using biofeedback therapy in the treatment of urinary incontinence for adults and children includes case studies, meta-analyses, and prospective studies (Burgio, 2002; Burgio, 2006; Dannecker, 2005; Desantis, 2011; Fitz, 2012; Hsu, 2016; Klijn, 2006).

In 2011, Herderschee and colleagues performed a Cochrane review to determine if biofeedback aided in pelvic floor muscle training for urinary incontinence in women. The authors reviewed 24 trials (n=1583), including 17 trials that examined the primary outcome. They found that women who received biofeedback reported better outcomes than those who received muscle training alone (risk ratio [RR] 0.75; 95% confidence interval [CI], 0.66 to 0.86). The authors recommended additional trials to determine if biofeedback, or general feedback from a healthcare practitioner, was responsible for the superior outcomes.

Moroni and colleagues (2016) performed a systematic review and meta-analysis of randomized controlled trials to assess conservative management of stress urinary incontinence for adult women. The authors included trials that compared pelvic floor muscle training (PFMT), with or without biofeedback, to no treatment (n=122) and PFMT versus PFMT plus biofeedback (n=250). The authors concluded:

The combination of biofeedback techniques during PFMT exercises seems not to lead to systematically better results when compared with PFMT alone in women that can adequately contract their pelvic floors, considering the included studies. Such combination, however, may be an option in women that cannot adequately isolate and contract such muscles.

In a guideline on the nonsurgical management of urinary incontinence in women (Qaseem, 2014), the American College of Physicians (ACP) states that “pelvic floor muscle training alone and in combination with bladder training or biofeedback and weight loss with exercise for obese women were effective at achieving continence and improving UI [urinary incontinence].”

The American Urological Society (AUA) published a guideline (Kobashi, 2017) that states pelvic floor muscle training, with or without biofeedback, should be offered to individuals with stress urinary incontinence or stress-predominant mixed urinary incontinence.

In a clinical guidelines practice bulletin on urinary incontinence in women (ACOG 2015; reaffirmed 2018), the American College of Obstetricians and Gynecologists (ACOG) states that “pelvic muscle exercises may be used alone or augmented with bladder training, biofeedback, or electrical stimulation. Pelvic floor muscle exercises can be effective as a first-line treatment for stress, urgency, or mixed urinary incontinence.”

Biofeedback for Chronic Constipation, Fecal Incontinence, and Anorectal Disorders

Woodward and colleagues (2014) performed a Cochrane review to examine the effectiveness and side effects of biofeedback therapy for the treatment of chronic constipation in adults. The researchers included 17 randomized studies (n=931) that compared different biofeedback methods, compared biofeedback to shams, or compared biofeedback to standard treatment. They found that supervised computer-assisted biofeedback was superior to sedatives, shams, laxatives, and lifestyle changes (diet and exercise). Some surgeries were found superior but had more side effects, whereas biofeedback was not found to cause any side effects or adverse events. However, due to the low quality of the studies, including the lack of a consistent protocol and the potential for bias, the researchers were not able to make a firm recommendation for biofeedback to treat constipation; further studies were recommended. Since then, additional studies have shown benefits of biofeedback for constipation (Ba-Bai-Ke-Re, 2014; Simón, 2017).

In a practice guideline (Wald 2014), the American College of Gastroenterology (ACG) states that “biofeedback is the preferred treatment for DD [disordered defecation] in adults (strong recommendation, moderate quality evidence).” They also stated that for chronic proctalgia (also known as levator ani syndrome, levator spasm, puborectalis syndrome, pyriformis syndrome, or pelvic tension myalgia), “biofeedback to teach relaxation of pelvic floor muscles during simulated defecation is the preferred treatment. (strong recommendation, moderate quality of evidence).”

The American Gastroenterological Association (AGA) released a medical position on constipation (Bharucha, 2013) that states the following:

Biofeedback therapy improves symptoms in more than 70% of patients with defecatory disorders. The motivation of the patient and therapist, the frequency and intensity of the retraining program, and the involvement of behavioral psychologists and dietitians as necessary all likely contribute to the chances of success…Pelvic floor retraining by biofeedback therapy rather than laxatives is recommended for defecatory disorders (strong recommendation, high-quality evidence).

The American Neurogastroenterology and Motility Society (ANMS) and the European Society of Neurogastroenterology and Motility (ESNM) created guidelines (Rao, 2015) on the efficacy of biofeedback and concluded the following:

Based on the strength of evidence, biofeedback therapy is recommended for the short term and long term treatment of constipation with dyssynergic defecation (Level I, Grade A), and for the treatment of fecal incontinence (Level II, Grade B). Biofeedback therapy may be useful in the short-term treatment of Levator Ani Syndrome with dyssynergic defecation (Level II, Grade B), and solitary rectal ulcer syndrome with dyssynergic defecation (Level III, Grade C), but the evidence is fair. Evidence does not support the use of biofeedback for the treatment of childhood constipation (Level 1, Grade D)…Treatment recommendations were based on grading recommended by the U.S. Preventive Services Task Force [https://‌www.‌uspreventive‌servicestaskforce‌.org].

In a clinical practice guideline for the evaluation and management of constipation (Paquette, 2016), the American Society of Colon and Rectal Surgeons (ASCRS) states that biofeedback is helpful for constipation and dyssynergic defecation (strong recommendation based on moderate-quality evidence, 1B).

In its medical position statement on anorectal testing techniques (Barnett, 1999), the AGA states that "neurogenic fecal incontinence associated with weakness of the external anal sphincter and/or decreased ability to perceive rectal distention because of nerve injury can be treated with biofeedback training."

The ACG states in a guideline addressing fecal incontinence (Wald, 2014) that “pelvic floor rehabilitative techniques [including manometric or EMG-assisted biofeedback therapy] are effective and superior to pelvic floor exercises alone in patients with FI [fecal incontinence] who do not respond to conservative measures (strong recommendation, moderate quality of evidence).” However, ACG further states that:

Biofeedback is not indicated in patients with isolated internal anal sphincter weakness, overflow incontinence associated with behavioral or psychiatric disorders, neurological disorders associated with substantial loss of rectal sensation and/or the inability to contract the striated muscles, decreased rectal storage capacity from resection, inflammation or fibrosis, or major structural damage to continence mechanisms.

In a practice guideline (Paquette, 2015) for the treatment of fecal incontinence, the ASCRS states that “biofeedback should be considered as an initial treatment for patients with incontinence and some preserved voluntary sphincter contraction. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.”

Biofeedback for Chronic Back Pain and Cancer Pain

In a meta-analysis on the efficacy of biofeedback for chronic back pain, Sielski and colleagues (2017) evaluated 21 studies (n=1062). They found a significant small to medium effect size for pain intensity reduction (Hedges’ g=0.60; 95% CI, 0.44 to 0.76) that was stable with a significant small-to-large effect size (Hedges’ g=0.62; 95% CI, 0.40 to 0.84) over an average of 8-months follow-up. The researchers also found improvement in depression, disability, muscle tension, and coping. They concluded that biofeedback improved short and long-term pain-related outcomes for chronic back pain.

A 2010 practice guideline from the American Society of Anesthesiologists (ASA) Task Force on chronic pain management and the American Society of Regional Anesthesia and Pain Medicine (ASRA) states that “cognitive behavioral therapy, biofeedback, or relaxation training may be used as part of a multimodal strategy for low back pain and for other chronic pain conditions.”

In a clinical practice guideline on treatments for back pain (Qaseem, 2017), the ACP recommends that clinicians should initially prescribe nonpharmacologic treatment for chronic low back pain, including electromyography biofeedback (Grade: strong recommendation).

The American College of Occupational and Environmental Medicine (ACOEM) 2016 guidelines on low back disorders recommends biofeedback “for highly select patients with chronic low back pain as part of a multi-disciplinary rehabilitation program” (Strength of evidence: recommended, insufficient evidence (I); level of confidence: low).

In their guidelines on adult cancer pain (V.1.2018), the National Comprehensive Cancer Network (NCCN) recommends biofeedback as an evidence-based treatment modality (2A recommendation).

Biofeedback and Neurofeedback (EEG Biofeedback) for Other Conditions

At this time, there is insufficient or conflicting evidence in the peer-reviewed literature comparing biofeedback to established treatment modalities (for example, pharmacotherapy or behavior therapy) to conclude that biofeedback therapies or neurofeedback (EEG biofeedback) are effective treatments for other conditions, including, but not limited to: anxiety and panic disorders (Goessl, 2017; Hammond, 2005; Mennella, 2017), asthma, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD) (Benner-Davis, 2007; Cortese, 2016; Drechsler, 2007; Duric, 2017; Gevensleben, 2009; Gevensleben, 2010; Holtmann, 2006; Lee, 2017; Leins, 2007; Levesque, 2006; Monastra, 2005 and 2008), attention-impulse disorder (Arns, 2009; Logemann, 2010), autism spectrum disorders (ASD) (Coben, 2010; Kouijzer, 2013), Bell’s palsy (Cardosa, 2008); cardiovascular disease (Climov, 2014; Michael, 2005), cluster headache, cognitive performance (Angelaksi, 2007; Schwenk, 2016); depression (Siepmann, 2008; Young, 2017), dyslexia (Breteler, 2010), endometriosis-associated pain (Grego, 2003), epilepsy (Jackson, 2015; Kotchoubey, 1999; Lantz, 1988; Nagai, 2018; Ramaratnam, 2005; Strehl, 2014; Tan, 2009), fibromyalgia (Babu, 2007; Baranowsky, 2009; Nelson, 2010; Theadom, 2015; Thieme, 2009), hypertension (Greenhalgh, 2009; Nakao, 2003; Nolan, 2010; Olsson, 2010; Rainforth, 2007), insomnia and sleep disorders (Cortoos, 2010; Schabus, 2017), learning disabilities, menopausal hot flashes, movement disorders (including Parkinson’s disease), obsessive-compulsive disorder (Deng, 2014), orthostatic hypotension associated with spinal cord injury (Gillis, 2008), posttraumatic stress disorder (PTSD) (Rosaura Polak, 2015; van der Kolk, 2016; Zucker, 2009), Raynaud’s syndrome (Malenfant, 2009; Middaugh, 2001), relaxation (Egner, 2007; van der Zwan, 2015), seizure disorders, stroke (Renton, 2017), tinnitus (Emmert, 2017; Weise, 2008), traumatic brain injury, or substance abuse-related disorders (Gerchen, 2018; Keith, 2015; Scott, 2005; Sokhadze, 2008). Limitations reported by these studies and meta-analysis include lack of randomization or comparison to conventional therapies, lack of a control group, measurements of short-term outcomes with limited follow-up periods, or small participant populations.

The American Academy of Pediatrics (AAP) clinical practice guideline on ADHD in children and adolescents (AAP, 2011) recommends future research on electroencephalographic biofeedback.

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 home settings.



Biofeedback is a training program where an individual is given information about physiological processes through electronic monitoring, with the goal of gaining conscious control and influencing those processes. Examples of such physiologic processes include heart rate, blood pressure, and muscle tension. The theory of biofeedback is that these processes are related to a disorder, and by controlling the physiologic process, an individual also controls the disorder. Different types of biofeedback modalities are utilized depending on the individual’s symptoms or condition. Examples of different biofeedback methods include electromyography (EMG), thermal, heart variability, and galvanic skin response.


Neurofeedback (also known as EEG biofeedback) describes the feedback of neural information and has been investigated as a treatment for a variety of conditions including ADHD, anxiety disorders, panic disorders, depression, learning disabilities, menopausal hot flashes, seizure disorders, sleep disorders, stress management, substance abuse disorders, or traumatic brain injury. Although related in concept to biofeedback, neurofeedback differs in that the information fed back to the individual is a direct measure of brain activity rather than of a specific physiological process. The individual may be trained to either increase or decrease the prevalence, amplitude, or frequency of specified EEG waveforms (alpha, beta, or theta waves), depending on the desired changes. The theory of neurofeedback is that certain medical and psychological disorders are associated with specific waveforms, and when an individual learns to control those waveforms, the disorder can be controlled.



Biofeedback: The use of sensory input, such as visual or auditory signals, to make unconscious or involuntary body processes perceptible. Conscious control of the processes is intended to diminish adverse signs and symptoms of a medical condition.

Electroencephalography (EEG) biofeedback (also called Neurofeedback): A biofeedback method intended to gain control of brain wave activity with the goal of improving a medical or psychological condition.

Electromyography (EMG) biofeedback: A biofeedback method intended to gain control of muscle tension.

Galvanic skin response biofeedback: A biofeedback method intended to gain control of body sweating.

Heart variability biofeedback: A biofeedback method intended to gain control of heart rate.

Thermal biofeedback: A biofeedback method intended to gain control of body temperature.


The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary for biofeedback techniques excluding EEG biofeedback:




For the following codes when specified as peripheral skin temperature feedback, blood-volume-pulse feedback (vasoconstriction and dilation), vasoconstriction training (temporalis artery), and manometric or electromyographic biofeedback:


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


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


Biofeedback training by any modality


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



ICD-10 Diagnosis





Tension type headache


Neoplasm related pain




Anal spasm


Other specified diseases of anus and rectum




Stress incontinence, other specified urinary incontinence


Fecal incontinence

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:




For the following CPT codes when specified as EEG biofeedback or neurofeedback:


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


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


Biofeedback training by any modality






Electromyography (EMG), biofeedback device



ICD-10 Diagnosis



All diagnoses


Peer Reviewed Publications:

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Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatrics (AAP). ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. 2011. Available at: Accessed on October 15, 2018.
  2. American College of Occupational and Environmental Medicine (ACOEM). Low back disorders. 2016. Available at: Accessed on October 15, 2018.
  3. American College of Obstetricians and Gynecologists (ACOG). ACOG practice bulletin no. 155: urinary incontinence in women. Obestet Gynecol. 2015(reaffirmed 2018); 126(5):e66-81.
  4. American Society of Anesthesiologists (ASA). Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists task force on chronic pain management and the American Society of Regional Anesthesia and Pain Medicine. 2010. Available at: http://‌‌article.aspx?articleid=1932775&_ga=2.238373385.804795807.1533237254-1328391640.1501180305. Accessed on October 15, 2018.
  5. Barnett JL, Hasler WL, Camilleri M. American Gastroenterological Association medical position statement on anorectal testing techniques. Gastroenterology. 1999; 116(3):732-760.
  6. Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013; 144(1):211-217.
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  8. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Biofeedback. NCD #30.1 Effective date not posted. Available at: Accessed on October 15, 2018.
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  12. Locke GR 3rd, Pemberton JH, Phillips SF. AGA technical review on constipation. Gastroenterology. 2000; 119(6):1766-1778.
  13. NCCN Clinical Practice Guidelines in Oncology®. ©2018 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: Accessed on October 15, 2018.
  1. Paquette IM, Varma MG, Kaiser AM, et al. The American Society of Colon and Rectal Surgeons' clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. 2015; 58(7):623-636.
  2. Paquette IM, Varma M, Tement C, et al. The American Society of Colon and Rectal Surgeons' clinical practice guideline for the evaluation and management of constipation. Dis Colon Rectum. 2016; 59(6):479-492.
  3. Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014; 161(6):429-440.
  4. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the american college of physicians. Ann Intern Med. 2017; 166(7):514-530.
  5. Rao SS, Benninga MA, Bharucha AE, et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil. 2015; 27(5):594-609.
  6. Renton T, Tibbles A, Topolovec-Vranic J. Neurofeedback as a form of cognitive rehabilitation therapy following stroke: A systematic review. PloS One. 2017; 12(5):e0177290.
  7. Scott Morey S. Practice guidelines of the American Academy of Family Physicians (AAFP). Guidelines on migraine: part 4. General principles of preventive therapy. Am Fam Physician. 2004; 62(1):2359-2360, 2363.
  8. 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.
  9. Theadom A, Cropley M, Smith HE, et al. Mind and body therapy for fibromyalgia. Cochrane Database Syst Rev. 2015;(4):CD001980.
  10. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014; 109(8):1141-1157.
  11. Woodward S, Norton C, Chiarelli P. Biofeedback for treatment of chronic idiopathic constipation in adults. Cochrane Database Syst Rev. 2014;(3):CD008486.
Websites for Additional Information
  1. Association for Applied Psychophysiology and Biofeedback (AAPB). Available at: Accessed on October 15, 2018.
  2. National Institute of Neurologic Disorders and Stroke (NINDS). Headache information page. July 13, 2018. Available at: Accessed on October 15, 2018.

EEG Biofeedback (Neurofeedback)

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.

Document History






Medical Policy & Technology Assessment Committee (MPTAC) review. Rationale, References, and Websites sections updated.



MPTAC review. Initial document development.