E0746, Electromyography (emg), biofeedback device
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- When outcomes or objective measures are used in studies, documentation may include pre- and post-treatment objective testing/results (e.g., anal manometry, Vaizey score, Wexner Incontinence Scores, FI-QOL scores, number of complete spontaneous bowel movements, EMG measures, HRV measures, Berg Balance Scale, Timed Up and Go, treadmill gait kinematics, headache frequency/intensity diaries).
- This document does not state explicit documentation requirements (no listed required medical records, specific test results, or required clinical notes).
- General implication from evidence summaries: objective baseline and follow-up measures relevant to the condition should be documented (e.g., validated symptom scales such as BPI for pain, ASEBA or Clinician-Administered PTSD Scale for PTSD, IBS-SSS for IBS, GMFM for cerebral palsy), though no formal documentation checklist is provided in the text.
- For chronic constipation secondary to dyssynergic defecation: documentation that dyssynergic defecation is confirmed by anorectal manometry.
- For fecal incontinence: documentation of suitable candidacy (some degree of rectal sensation and ability to contract the sphincter voluntarily) and documentation that first-line therapies (behavior modification and pharmacotherapies) have been tried and failed.
- For urinary incontinence: documentation that behavioral techniques (pelvic muscle exercises, bladder training) have been attempted as first-line therapy and that biofeedback is being used in combination with these techniques as appropriate.
Key Coverage Criteria
- Covered indications: TMJ disorders may be treated with nonsurgical services including arthrocentesis; intra-articular corticosteroid injections; trigger point injections; physical therapy; and occlusal splints (stabilization and repositioning).
- Cancer pain
- Fecal incontinence
- ICD-10 N31.9 Neurogenic bladder dysfunction NOS
- ICD-10 N32.81 Overactive bladder
- ICD-10 N32.89 Other specified disorders of bladder [non-neuropathic voiding disorders]
20 Active Policies
ANTHEM-MED.00130, MED.00130 Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring
ANTHEM-CG-MED-97, CG-MED-97 Biofeedback and Neurofeedback
UHC-POL-temporomandibular-joint-disorders, Treatment of Temporomandibular Joint Disorders
AETNA-CPB-0132, Biofeedback
AETNA-CPB-0679, Levator Syndrome Treatments
PSY301.018, Biofeedback as a Treatment of Chronic Pain
PSY301.019, Biofeedback as a Treatment of Headache
PSY301.016, Biofeedback as a Treatment of Urinary Incontinence
BCBSIL-PSY301.018, Biofeedback as a Treatment of Chronic Pain
BCBSIL-PSY301.019, Biofeedback as a Treatment of Headache
BCBSIL-PSY301.016, Biofeedback as a Treatment of Urinary Incontinence
BCBSIL-PSY301.007, Biofeedback for Miscellaneous Indications
BCBSIL-SUR705.010, Temporomandibular Joint Disorders
BCBSMT-PSY301.018, Biofeedback as a Treatment of Chronic Pain
BCBSMT-PSY301.019, Biofeedback as a Treatment of Headache
BCBSMT-PSY301.016, Biofeedback as a Treatment of Urinary Incontinence
BCBSMT-PSY301.007, Biofeedback for Miscellaneous Indications
BCBSMT-SUR705.010, Temporomandibular Joint Disorders
BCBSNM-PSY301.018, Biofeedback as a Treatment of Chronic Pain
BCBSNM-PSY301.019, Biofeedback as a Treatment of Headache
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