Biofeedback Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient has requested authorization and coverage for weekly biofeedback therapy, weekly eye movement desensitization and reprocessing therapy (EMDR), weekly internal family systems (IFS) for trauma, weekly PTSD acceptance and commitment therapy (ACT), and weekly cognitive hypnosis, somatic experiencing, positive psychology and resilience therapy. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for biofeedback therapy Findings: Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Neurofeedback is a specific form of biofeedback that involves an encephalogram (EEG). This modality is utilized to improve brainwave activity, particularly in patients with anxiety disorder. The study by Surmeli and Ertem evaluated 36 patients with obsessive-compulsive disorder who were treated with neurofeedback. Per the authors, 33 out of 36 patients who received neurofeedback training showed clinical improvement.

Where the denial was upheld

A 39-year-old female has requested coverage for past and future services for formal pelvic floor therapy, electrostimulation and biofeedback therapy for treatment of her interstitial cystitis. Findings: Two physician reviewers found that the patient has a history of irritative symptoms that have not recently been associated with urinary tract infections (UTIs). The patient had a period of frequent UTI symptoms, which persisted despite treatment. She was found to be negative for a nuclear matrix protein 22, however, a cystoscopy did show erythematous areas. The patient has received intravesical instillations of kenalog, sodium bicarbonate, lidocaine, sterile water and heparin. The patient also underwent treatment with pelvic floor therapy, electrostimulation and biofeedback therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for biofeedback therapy. The long-term efficacy of biofeedback in addition to standard pelvic floor pelvic therapy for management of patients with urinary incontinence remains unknown. A recent randomized trial concluded that, “this preliminary study suggests that pelvic floor muscle training, with and without biofeedback, is associated with increased muscle strength, myoelectric activity, precontraction of pelvic floor muscles, and improved quality of life in postmenopausal women with stress urinary incontinence.” Researchers found that pelvic floor muscle training is effective for treatment of stress urinary incontinence.

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 Therapy, then check the rights and deadlines that apply to your plan.