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Neurofeedback describes techniques of providing feedback about neuronal activity, as measured by electroencephalogram (EEG) biofeedback or functional magnetic resonance imaging (fMRI), to teach patients to self-regulate brain activity. Neurofeedback may utilize several techniques in an attempt to normalize unusual patterns of brain function in patients with a variety of psychiatric and central nervous system (CNS) disorders.
Neurofeedback may be conceptualized as a type of biofeedback that traditionally used the electroencephalogram (EEG) as a source of feedback data. Neurofeedback differs from traditional forms of biofeedback in that the information fed back to the patient (via EEG tracings, fMRI, near-infrared spectroscopy) is a direct measure of global neuronal activity or brain state, compared with feedback of the centrally regulated physiological processes such, as tension of specific muscle groups or skin temperature. The patient may be trained to either increase or decrease the prevalence, amplitude or frequency of specified EEG waveforms (e.g., alpha, beta, theta waves), depending on the changes in brain function associated with the particular disorder. It has been proposed that training of slow cortical potentials (SCPs) can regulate cortical excitability and that using the EEG as a measure of CNS functioning can help train patients to modify or control their abnormal brain activity. Upregulating or downregulating neural activity with real-time feedback of fMRI signals is also being explored.
Neurofeedback is being investigated for the treatment of a variety of disorders including autism spectrum disorder, insomnia, learning disabilities, Tourette syndrome, traumatic brain injury, seizure disorders, menopausal hot flashes, panic and anxiety disorders, fibromyalgia, tinnitus, substance abuse disorders, eating disorders, depression, stress management, migraine headaches, stroke, Parkinson disease, premenstrual dysphoric disorder, posttraumatic stress disorder, and sleep disorders. Two EEG training protocols, training of slow cortical potentials (SCPs) and theta/beta training, are typically used in children with attention-deficit/hyperactivity disorder (ADHD). For training of SCPs, surface-negative SCPs and surface-positive SCPs are generated over the sensorimotor cortex. Negative SCPs reflect increased excitation and occur during states of behavioral or cognitive preparation, while positive SCPs are thought to indicate reduction of cortical excitation of the underlying neural networks and appear during behavioral inhibition. In theta/beta training, the goal is to decrease activity in the EEG theta band (4-8 hertz [Hz]) and increase activity in the EEG beta band (13-20 Hz), corresponding to an alert and focused but relaxed state. Alpha-theta neurofeedback is typically used in studies on substance abuse. Neurofeedback protocols for depression focus on alpha interhemispheric asymmetry and theta/beta ratio within the left prefrontal cortex. Neurofeedback for epilepsy has focused on sensorimotor rhythm up-training (increasing 12-15 Hz activity at motor strip) or altering slow cortical potentials. It has been proposed that learned alterations in EEG patterns in epilepsy are a result of operant conditioning and are not conscious or voluntary. A variety of protocols have been described for treatment of migraine headaches.
A number of EEG-feedback systems (EEG hardware and computer software programs) have been cleared for marketing through the 510(k) process. For example, the BrainMaster™ 2E (BrainMaster Technologies) is “indicated for relaxation training using alpha EEG Biofeedback. In the protocol for relaxation, BrainMaster™ provides a visual and/or auditory signal that corresponds to the patient’s increase in alpha activity as an indicator of achieving a state of relaxation.” Although devices used during neurofeedback may be subject to U.S. Food and Drug Administration (FDA) regulation, the process of neurofeedback itself is a procedure, and, therefore, not subject to FDA approval.
Neurofeedback is considered investigational.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/2002: Approved by Medical Policy Advisory Committee (MPAC)
8/26/2005: Code Reference section reviewed, no changes
8/31/2006: Policy reviewed, no changes
6/19/2009: Policy reviewed, no changes
6/26/2009: Policy Description section updated
09/09/2010: Policy description updated to add information regarding neurofeedback for epilespy. Policy statement unchanged.
09/23/2011: Policy reviewed. Policy description updated; policy statement unchanged.
10/23/2013: Policy review; no changes.
08/15/2014: Policy reviewed; description updated. Policy statement unchanged.
08/17/2015: Medical policy revised to add ICD-10 codes.
10/26/2015: Policy description updated regarding devices. Policy statement unchanged. Investigative definition updated in policy guidelines section.
Blue Cross Blue Shield Association Policy # 2.01.28
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.