E3200 — Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- There should be a written treatment plan which must include: the specific diagnosis/conditions to be treated; long- and short-term goals; measurable objectives; the time frame and the frequency of treatment in which the goals and objectives will be achieved.
- Patients must be cognitively intact and willing and motivated to learn and practice the specific tasks needed to correct/improve their problems.
- Biofeedback must be performed by a licensed healthcare professional or qualified non-physician practitioner (examples given: physical and occupational therapists in independent practice, nurse practitioners, physician assistants, clinical nurse specialists).
- Biofeedback must be performed in a clinical setting with continuous one-on-one face-to-face presence of the physician or qualified practitioner during training (documentation should reflect this).
Key Coverage Criteria
- Biofeedback performed by a licensed healthcare professional is considered medically necessary for Chronic constipation with dyssynergic defecation (adults only).
- Biofeedback performed by a licensed healthcare professional is considered medically necessary for Fecal incontinence for patients with: some degree of rectal sensation; ability to contract the sphincter voluntarily; and failure/intolerance/contraindication of treatment with dietary changes, devices or drugs.
- Biofeedback performed by a licensed healthcare professional is considered medically necessary for Stress, urgency, mixed, or overflow urinary incontinence when there is failure/intolerance/contraindication of other nonpharmacologic treatment (e.g., bladder training and/or pelvic floor muscle training [PFMT]) (children and adults).
- Biofeedback performed by a licensed healthcare professional is considered medically necessary for Migraine and tension headaches (children and adults) as part of a comprehensive treatment plan.
- Biofeedback performed by a licensed healthcare professional is considered medically necessary for Muscle re-education of specific extremity muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness when: patient is diagnosed with stroke, and failure/intolerance/contraindication of conventional treatments (e.g. modalities, massage, soft tissue mobilization, exercise).
- Biofeedback performed by a licensed healthcare professional is considered medically necessary for Refractory levator ani syndrome (e.g. proctalgia fugax, chronic anal pain syndrome, anal spasm) with dyssynergic defecation when: condition is not neurological or disease-based, and there is failure/intolerance/contraindication of conservative treatment including high-fiber diet; withdrawal of drugs that cause constipation (e.g., calcium channel blockers, narcotics) or diarrhea (e.g., antibiotics, q [...]
2 Active Policies
CIGNA-CPG294 — Biofeedback - (CPG294)
REGENCE-MED175.06 — Digital Therapeutic Products for Gait Training
Related Codes
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