90911
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that member is cognitively and physically capable and motivated to participate in the biofeedback plan of care; for children, documentation that caregiver support/guidance is available.
- Documentation of a failed, documented 4-week trial of pelvic muscle exercise training for adult urinary incontinence.
- Documentation that alternative treatments for pediatric dysfunctional voiding were attempted and unsuccessful (examples: timed voiding, prophylactic antibacterial therapy for recurrent UTIs, short-term anticholinergic medications).
- Anorectal manometry report demonstrating external anal sphincter weakness when used to support fecal incontinence indication.
Key Coverage Criteria
- Member is cognitively and physically capable of participating in and motivated to follow the agreed plan of care (for children, caregiver support/guidance must be available).
- Adult urinary incontinence (stress, urge, or mixed) when member has failed a documented 4-week trial of pelvic muscle exercise training.
- Dysfunctional voiding in children when other treatment options (e.g., timed voiding, prophylactic antibiotics for recurrent UTIs, short-term anticholinergic therapy) have been unsuccessful.
- Fecal incontinence with either anorectal manometry demonstrating external anal sphincter weakness or decreased ability to perceive rectal distension due to nerve injury, provided none of the contraindications listed below are present.
- Chronic constipation characterized by dyssynergic defecation.
- Tension or migraine headaches.
1 Active Policy
AMBETTER-CP.MP.168 — Biofeedback
Related Codes
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