Medical policy: Biofeedback as a Treatment of Chronic Pain; (Formerly Biofeedback and Neurofeedback Therapy)

Policy number: MP 2.064

Effective date: 9/1/2026

Policy

Biofeedback may be considered medically necessary for chronic back and neck pain.

Biofeedback may be considered medically necessary for the treatment of cancer-related pain.

Biofeedback as a treatment of chronic pain in all other situations is investigational. There is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with this procedure for the above indications.

Cross-reference:

• MP 1.033 Sacral Nerve Neuromodulation-Stimulation
• MP 2.029 Neurofeedback
• MP 2.062 Temporomandibular Disorder
• MP 2.096 Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
• MP 2.304 Medical Treatments of Autism Spectrum Disorders
• MP 2.398 Biofeedback as a Treatment of Fecal Incontinence or Constipation
• MP 2.399 Biofeedback as a Treatment of Urinary Incontinence in Adults
• MP 2.400 Biofeedback as a Treatment of Headache
• MP 2.401 Biofeedback for Miscellaneous Indications
• MP 4.012 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
• MP 6.020 Transcutaneous Electrical Nerve Stimulation and Transcutaneous Afferent Patterned Stimulation

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Description/Background

Biofeedback as a Treatment of Chronic Pain

Biofeedback is intended to teach individuals self-regulation of certain physiologic processes not normally considered to be under voluntary control. The various forms of biofeedback mainly differ in the nature of the disease or disorder under treatment, the biologic variable that the subject attempts to control, and the information that is fed back to the subject.

Biofeedback techniques include peripheral skin temperature feedback, blood-volume-pulse feedback (vasoconstriction and dilation), vasoconstriction training (temporalis artery), and electromyographic biofeedback; they may be used alone or in conjunction with other therapies (e.g., relaxation, behavioral management, medication). Biofeedback training is done either in individual or group sessions. A typical program consists of 10 to 20 training sessions of 30 minutes each.

Biofeedback has been proposed as a treatment for a variety of diseases and disorders, including anxiety, headaches, hypertension, movement disorders, incontinence, pain, asthma, Raynaud disease, and insomnia.

Treatment for chronic pain is often multimodal and typically includes psychological therapy. Psychological techniques vary but may include cognitive therapy, which teaches subjects the ability to cope with stressful stimuli by attempting to alter negative thought patterns and dysfunctional attitudes, and behavioral approaches to reduce muscle tension and break the pain cycle. Relaxation, using any of a variety of techniques including meditation or mental imagery, is considered a behavioral therapy that may be used alone or as a component of a cognitive-behavioral therapy (CBT) program. Electromyography (EMG) biofeedback has also been used for the treatment of chronic pain, on the assumption that the ability to reduce muscle tension will be improved through feedback of data to the patient regarding degree of muscle tension. While some consider EMG biofeedback to be a method to obtain relaxation, others consider biofeedback to be distinct from other relaxation techniques.

Regulatory Status

A variety of biofeedback devices have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. These devices are designated by the FDA as class II with special controls and are exempt from premarket notification requirements. The FDA defines a biofeedback device as “an instrument that provides a visual or auditory signal corresponding to the status of 1 or more of a patient’s physiological parameters (e.g., brain alpha wave activity, muscle activity, skin temperature, etc.) so that the patient can control voluntarily these physiological parameters.”

Evidence pertaining to the use of biofeedback for urinary incontinence is addressed in evidence review in MP 2.399.

Evidence pertaining to the use of biofeedback for headaches is addressed in evidence review in MP 2.400.

Evidence pertaining to the use of biofeedback for miscellaneous indications (treatment of hypertension, anxiety, asthma, movement disorders [e.g, motor function after stroke, injury, or lower-limb surgery], and other applications) is addressed in evidence review in MP 2.401.

Evidence pertaining to the use of biofeedback for fecal incontinence or constipation is addressed in evidence review in MP 2.398.

Rationale

Summary of evidence

Biofeedback as a Treatment of Back Pain and Cancer Pain

For individuals who have chronic pain who receive biofeedback, the evidence includes multiple RCTs for different pain syndromes. Relevant outcomes are symptoms, functional outcomes, quality of life, and medication use. 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. 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).

In their guidelines on adult cancer pain (V.2.2025), the National Comprehensive Cancer Network (NCCN) recommends biofeedback as an evidence-based treatment modality in reference to referral to mental health consultation (2A recommendation).

Biofeedback as a Treatment of Chronic Pain

For individuals who have chronic pain who receive biofeedback, the evidence includes multiple randomized controlled trials (RCTs) for different pain syndromes. Relevant outcomes are symptoms, functional outcomes, quality of life, and medication use. The results of these RCTs, some of which were sham-controlled, did not consistently report a benefit for biofeedback. Some RCTs reported improved outcomes with biofeedback, but these improvements were often of uncertain clinical significance or were not durable. Many other RCTs have found that biofeedback did not provide a significantly greater benefit in outcomes when it was used instead of or in addition to other conservative interventions such as exercise. Overall, the available RCTs were limited by small sample sizes and high dropout rates. This evidence base does not permit conclusions about the specific effects of biofeedback beyond the nonspecific effects of sham interventions, nor does it permit conclusions about the contribution of biofeedback beyond that of other conservative treatments for pain. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Definitions

Electromyogram (EMG): is the graphic record of resting and voluntary muscle activities as a result of electrical stimulation.

Physiologic: pertains to normal functions of the human body as opposed to pathological.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These polices are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Covered when medically necessary:

*Covered when both psychotherapy & biofeedback are provided

References

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