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TRICARE Policy Manual 6010.63-M, April 2021
Medicine
Chapter 7
Section 4.1
Biofeedback
Issue Date:  January 23, 1984
Authority:  32 CFR 199.4(e)(17)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT CODES
90901, 90911
2.0  DESCRIPTION
Biofeedback therapy is a technique by which a person is taught to exercise control over a physiologic process occurring within the body. By using modern biomedical instruments the patient learns how a specific physiologic system within his body operates and how to modify the performance of this particular system.
3.0  POLICY
Benefits are payable for services and supplies in connection with electrothermal, electromyograph and electrodermal biofeedback therapy when there is documentation that the patient has undergone an appropriate medical evaluation, that their present condition is not responding to or no longer responds to other forms of conventional treatment and only provided in treatment of the following conditions:
3.1  Adjunctive treatment for Raynaud’s Syndrome.
3.2  Adjunctive treatment for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, or incapacitating muscle spasm or weakness.
3.3  Payable benefits include initial intake evaluation. Treatment following the initial intake evaluation is limited to a maximum of 20 inpatient and outpatient biofeedback treatments per calendar year.
4.0  EXCLUSIONS
4.1  Treatment of ordinary muscle tension states or for psychosomatic conditions.
4.2  Rental or purchase of biofeedback equipment.
4.3  Hypertension.
4.4  Treatment of psychosomatic (i.e., psychophysiological or psychological factors affecting medical condition) conditions and for Current Procedural Terminology (CPT) codes 90875 and 90876.
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