Biofeedback denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 16-year-old female with a history of pelvic/groin pain. She has migratory pain in the lower abdominal quadrants and groin, right side greater than left. The pain is constant and always present, but can increase to as high as 7/10. She also complains of shoulder pain. She has a history of chronic bilateral frontal headaches, reported as migraines. She has undergone extensive workup in the past for the cause of her pain. Workup included multiple negative laboratory examinations, CT scans and abdominal pelvic ultrasounds. It also included extensive physical evaluations by multiple physicians. The patient has been evaluated and treated by a psychotherapist who feels no significant psychopathology is present. She has taken multiple medications including large doses of neuropathic pain medications such as Neurontin, trileptal, lidocaine and Ultram.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for biofeedback services. Biofeedback has been shown to be beneficial to the treatment of patients with urinary problems when used as supplemental therapy. In addition, data from peer-reviewed medical literature reports that biofeedback can be beneficial for patients who have failed other treatment. In this case, the patient was being managed with pessary and physical therapy. Biofeedback can help allow female patients to isolate pelvic floor accessory muscles during pelvic floor contractions, which can aide in treatment of urinary issues. Thus, pelvic floor physical therapy with biofeedback was an appropriate next step and consistent with standard of care in the management of this patient’s symptoms.

Where the denial was upheld

Physician 1: The patient is a 27-year-old female who states that she has had problems with anxiety and panic episodes since adolescence. She has presented herself to the Emergency Department on two occasions for panic attacks manifested by dizziness, palpitations and difficulty concentrating. The patient has had trials of Celexa and Xanax but no information is available concerning the effect of these medications on her anxiety and panic episodes. She was referred by her primary care provider for a consultation with an integrative medicine specialist in May 2006. The specialist recommended a treatment plan including yoga, hypnosis and biofeedback and made a referral to a psychotherapist as well. It is not known from the record if the patient pursued psychotherapy.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) testing body biofeedback, (2) non-invasive vagus nerve stimulation, (3) electrical stimulation, and (4) vestibular rehabilitation. Findings: The physician reviewer found that the patient has multiple psychiatric diagnoses, but presents predominantly with somatic symptoms and without insight into his psychiatric diagnoses. While the patient has been evaluated for treatment-resistant depression, his presentation, based on the clinical documentation, appears to be most consistent with a primary psychotic disorder.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Biofeedback, then check the rights and deadlines that apply to your plan.