Medical policy: Neurofeedback

Policy number: MP 2.029

Effective date: 9/1/2026

Policy

Neurofeedback is considered 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 2.062 Temporomandibular Disorder
• MP 2.064 Biofeedback as a Treatment of Chronic Pain
• 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:

https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-management-guidelines/medical-policies.

Description/Background

Disorders of the Central Nervous System

Various disorders involve abnormal brain activity, including autism spectrum disorder, insomnia and sleep disorders, learning disabilities, Tourette syndrome, traumatic brain injury, seizure disorders, premenstrual dysphoric disorder, menopausal hot flashes, depression, stress management, panic and anxiety disorders, posttraumatic stress disorder, substance abuse disorders, eating disorders, migraine headaches, stroke, Parkinson disease, fibromyalgia, tinnitus, and attention-deficit/hyperactivity disorder (ADHD).

Treatment

Neurofeedback is being investigated for the treatment of a variety of disorders. Neurofeedback may be conceptualized as a type of biofeedback that has traditionally used the electroencephalogram (EEG) as a source of feedback data. Neurofeedback differs from established forms of biofeedback in that the information fed back to the patient (via EEG tracings, functional magnetic resonance imaging, near-infrared spectroscopy) is a direct measure of global neuronal activity, or brain state, compared with feedback of the centrally regulated physiologic processes, such as tension of specific muscle groups or skin temperature. The patient may be trained to 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 central nervous system functioning can help train patients to modify or control their abnormal brain activity. Upregulating or downregulating neural activity with real-time feedback of functional magnetic resonance imaging signals is also being explored.

Two EEG-training protocols (training of SCPs, theta/beta training) are typically used in children with ADHD. For training of SCPs, surface-negative 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 a 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 to 8 Hz) and increase activity in the EEG beta band (13 to 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 to 15 Hz activity at motor strip) or altering SCPs. 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 the treatment of migraine headaches.

Regulatory Status

A number of EEG feedback systems (EEG hardware and computer software programs) have been cleared for marketing by the U.S. Food and Drug Administration (FDA) 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 FDA regulation, the process of neurofeedback itself is a procedure, and, therefore, not subject to FDA approval.

FDA product codes: HCC, GWQ.

Rationale

For individuals who have attention-deficit/hyperactivity disorder (ADHD) who receive neurofeedback, the evidence includes randomized controlled trials (RCTs) and meta-analyses. Relevant outcomes are symptoms, functional outcomes, and quality of life. Several meta-analyses and at least 5 additional moderately sized RCTs (n range, 144 to 202 patients) have compared neurofeedback with methylphenidate, biofeedback, cognitive behavioral therapy, cognitive training, physical activity, or sham neurofeedback. Collectively, these studies found either small or no benefit of neurofeedback. A meta-analysis also found no effect of neurofeedback on objective measures of attention and inhibition. Studies that used active controls have suggested that at least part of the effect of neurofeedback may be due to attention skills training, relaxation training, and/or other nonspecific effects. Also, the beneficial effects of neurofeedback are more likely to be reported by evaluators unblinded to treatment (parents) than by evaluators blinded to treatment (teachers), suggesting bias in the nonblinded evaluations. Additional research with blinded evaluations of outcomes is needed to demonstrate the effect of neurofeedback on ADHD. However, the completion dates for some registered trials of neurofeedback in ADHD have passed without publication of results, suggesting the potential for publication bias. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have disorders other than ADHD (e.g., chronic insomnia, epilepsy, substance abuse, pediatric brain tumors, and post-traumatic stress disorder) who receive neurofeedback, the evidence includes case reports, case series, comparative cohorts, small RCTs, and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and quality of life. For these other disorders, including psychiatric, neurologic, and pain syndromes, the evidence is poor, and several questions concerning clinical efficacy remain unanswered. Larger RCTs that include either a sham or active control are needed to evaluate the effect of neurofeedback for these conditions. However, the completion dates for some registered trials of neurofeedback in disorders other than ADHD have passed without publication of results, suggesting the potential for publication bias. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Definitions

Electroencephalograph (EEG) is an instrument for recording the electrical activity of the brain.

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 policies 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 member’s 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.

Investigational, and therefore not covered:

References

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