| MP 2.01.28 | Neurofeedback | |
| Medical Policy | ||
| Section Medicine |
Subsection | Last Review Status/Date Reviewed with literature search/6:2009 |
| Issue 6:2009 |
Original Policy Date 1/30/98 |
Return to Medical Policy Index |
Description
Neurofeedback describes techniques of providing feedback about neuronal activity, as measured by electroencephalogram (EEG), in order to teach patients to self-regulate brain activity. Also known as EEG biofeedback, several different techniques have been examined in an attempt to normalize unusual patterns of brain function in patients with central nervous system (CNS) disorders such as attention deficit/hyperactivity disorder and substance abuse disorder.
Neurofeedback may be conceptualized as a type of biofeedback that uses the electroencephalogram (EEG) as a source of feedback data. Neurofeedback differs from traditional forms of biofeedback in that the information fed back to the patient (i.e., EEG tracings) is a direct measure of global neuronal activity or brain state, compared to feedback of the centrally regulated physiological processes such as tension of specific muscle groups or skin temperature. The patient may be trained to either 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 can regulate cortical excitability, and that using the EEG as a measure of CNS functioning can help train patients to modify or control their abnormal brain activity. Neurofeedback is being explored for the treatment of a variety of disorders including attention deficit/hyperactivity disorder (ADHD), learning disabilities, traumatic brain injury, seizure disorders, substance abuse-related disorders, menopausal hot flashes, panic and anxiety disorders, fibromyalgia, tinnitus, substance abuse, depression, stress management, or sleep disorders. Two training protocols, training of slow cortical potentials (SCPs) and theta/beta training, are typically used in children with ADHD. For training of SCPs, surface-negative SCPs 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 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 (4-8 hertz [Hz]) and increase activity in the EEG beta band (13-20 Hz), corresponding to an alert and focused but relaxed state. Alpha-theta neurofeedback is typically used in studies on substance abuse.Related policies:
2.01.27 Biofeedback as a Treatment of Urinary Incontinence in Adults
2.01.29 Biofeedback as a Treatment of Headache
2.01.30 Biofeedback as a Treatment of Chronic Pain
2.01.53 Biofeedback for Miscellaneous Indications
2.01.64 Biofeedback as a Treatment of Fecal Incontinence
Policy
Neurofeedback is considered investigational.
Policy Guidelines
No applicable information
Benefit Application
BlueCard/National Account Issues
Neurofeedback may be administered either by a psychiatrist or psychologist.
Rationale
This policy was originally based on a 1997 TEC Assessment (1), which concluded that there were inadequate data to permit conclusions regarding the health outcome effects of neurofeedback for any indication. Among the 19 studies reviewed in the TEC Assessment, few were randomized controlled trials and those that were did not support the efficacy of neurofeedback in improving health outcomes. In addition, even among the randomized clinical trials, only 2 studies used appropriate control conditions. A literature update for the period between 1998 and October 2004 identified few a total of 5 relevant articles. (2-6) Literature review updates using the MEDLINE database, performed in June 2006, August 2007, and May 2009, indicate increasing interest in neurofeedback for a variety of conditions, although the scientific literature appears to be the most advanced for attention deficit/hyperactivity disorder (ADHD). (7) Relevant randomized or quasi-randomized controlled trials of neurofeedback are described here.
Literature Review Attention Deficit Hyperactivity Disorder A 2005 review/meta-analysis used criteria from the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation (ISNR) to assess the clinical efficacy of neurofeedback for ADHD. (8) The authors concluded that neurofeedback for ADHD was ranked at level 3 or 'probably efficacious' on a scale of 1 to 5, 1 being not empirically supported and 5 being efficacious and specific. The authors noted that benefits were reported in the 5 randomized group studies (totaling 214 patients) included in their analysis; however, the ranking for neurofeedback for ADHD was based on the need for further studies controlled for patient and therapist factors that could unduly influence outcomes. A study published in 2006 examined brain activity following neurofeedback in 15 children with ADHD. (9) The experimental subjects learned to inhibit the amplitude of theta waves (4 –7 Hz) and increase amplitude of beta waves (15 –18 Hz). Five children with ADHD were randomized to a non-treatment control condition. Functional magnetic resonance imaging revealed increased activation of the right anterior cingulate cortex, an area related to selective attention that previously was shown to be altered in children with ADHD. However, it could not be determined whether the change in brain function was related to the specific neural training program (decreasing the amplitude of theta waves and increasing the amplitude of beta waves) or to the additional attentional training received by the experimental group. A 2007 report from Europe compared neurofeedback training of slow cortical potentials (n =17) with a control group (n =13) who participated in a group cognitive/behavior training program. (10) The report stated that randomization was incomplete, because the age range in the group program had to be small, parents had to be available for intense training during neurofeedback, and some parents had a preference for one type of training. Results showed that children in the neurofeedback group improved more than children who had participated in a group therapy program, particularly for attention and cognition. However, parental support was found to account for more of the improvement than neurofeedback training performance. To control for nonspecific effects (attention training) and confounding variables (parental engagement), Gevensleben and colleagues compared neurofeedback with a control intervention of participation in a computerized attention skills training in a European study. (11) All children were drug-naïve or drug-free without concurring psychotherapy for at least 6 weeks before starting training. The two training conditions were designed to be as similar as possible, using computer games, positive reinforcement by a trainer, homework, and parental encouragement in using the skills/strategies learned during training in real-life situations. Both groups participated in two blocks of 9 sessions (about 100 minutes per session plus a break), with 2–3 sessions per week, and parents were informed that both treatments were expected to be beneficial, but were not informed as to which type of training their child had been assigned. A total of 102 children were randomized in a 3:2 ratio; 8 children were excluded due to need for medical treatment, or non-compliance with the study protocol by either the children or their parents, resulting in 59 children in neurofeedback and 35 in attention training (92% follow-up). SCP and theta/beta training were compared by starting with one type of training in the first block and then the other (counterbalanced order) in the second block. Investigator evaluations were performed by the teachers, and were thus not blinded to the treatment. At the end of training/testing, there were no significant differences in parents’ attitude toward the two training conditions or in the perceived motivation of their children. About 40% of the parents either did not know which training their child had participated in or guessed the wrong group. Both parents and teachers rated the neurofeedback group as more improved on the hyperactivity subcomponent of a Strength and Disabilities Questionnaire (e.g., SDQ, 19% vs. 3% improved) and on a German ADHD scale (e.g., 26% vs. 9% improved). Thirty children in the neurofeedback group (52%) and 10 children in the attention training group (29%) improved more than 25% in the German ADHD scale (odds ratio: 2.68), which was the primary outcome measure. Other components of the SDQ, including emotional symptoms, conduct problems, peer problems, and prosocial behavior, were not different between the two training conditions. No significant differences were noted between the two neurofeedback training protocols. Results of this randomized controlled study suggested that neurofeedback may have specific effects on attention and hyperactivity beyond those achieved by attention training and parental involvement. The authors concluded that future studies should further address the specificity of effects and how to optimize the benefit of neurofeedback as a treatment module for ADHD. Information on the durability of the treatment effect is also lacking. Substance Abuse In a controlled study of 120 substance abuse patients being treated on an inpatient basis reported in 2005, Scott et al concluded that patients randomized to neurofeedback had better rates of drug abstinence at 1-year follow-up and remained in treatment longer than patients given additional treatment time equal to time spent in neurofeedback sessions (77% vs. 44%, and an average of 135 days vs. 101 days p < 0.005). (12) After 46 treatment days, the authors also reported that the Test of Variables of Attention (TOVA) significantly improved and that 5 of 10 scales of the Minnesota Multiphasic Personality Inventory-2 significantly differed in a positive manner in the neurofeedback group. While the authors indicated that the patients and testers were blind to group assignment for TOVA and MMPI testing, it is not clear how patients could be kept unaware of their assigned treatment groups while living in a residential treatment facility. In addition, the authors do not describe the additional treatment given to the control group. These factors of blinding and additional treatment could confound outcomes. Moreover, abstinence was not confirmed by urine or serum testing. A 2008 systematic review of neurofeedback as a treatment for substance abuse disorders described difficulties in assessing the efficacy of this and other substance abuse treatments, including the lack of clearly established outcome measures, differing effects of the various drugs, presence of comorbid conditions, absence of a gold standard treatment, and use as an add-on to other behavioral treatment regimens. (13) The authors concluded that alpha-theta training, when combined with an inpatient rehabilitation program for alcohol dependency or stimulant abuse, would be classified as level 3 or “probably efficacious”. This level is based on beneficial effects shown in multiple observational studies, clinical studies, wait-list control studies, or within-subject or between-subject replication studies. The authors also noted that few large-scale studies of neurofeedback in addictive disorders have been reported, and a shortcoming of the evidence for alpha-theta training is that it has not been shown to be superior to sham treatment. Cognitive Performance One small (n =6) quasi-randomized, double-blind pilot study examined whether increasing peak alpha frequency would improve cognitive performance in older adults (70 –78 years of age). (14) Control subjects were trained to increase alpha amplitude or shown playback of one of the experimental subject’s sessions. Compared to controls, the experimental group showed improvements in speed of processing for 2 of 3 cognitive tasks (Stroop, Go/No-Go) and executive function in 2 tasks (Go/No-Go, n-back); other functional measures, such as memory, were decreased relative to controls. Relaxation A randomized controlled trial on neurofeedback for relaxation conducted by Egner and colleagues found that alpha-theta feedback resulted in greater theta/alpha ratios, as compared to mock feedback suggesting enhanced relaxation. (15) However, there was no difference in subjective reports as both groups reported significantly lower levels of activation after training sessions. Summary The scientific evidence does not permit conclusions concerning the effect of the technology on health outcomes; a number of questions regarding clinical efficacy remain to be answered before applying neurofeedback techniques to patients with ADHD or substance abuse disorder. Neurofeedback is considered to be investigational; therefore, the policy statement remains unchanged. Technology Assessments, Guidelines and Position Statements The American Psychological Association (APA) provides general information on biofeedback (including neurofeedback) on their Web site “APA Online,” stating that “Biofeedback helps treat some illness, may boost performance, helps people relax and is even used to help children with Attention Deficit-Hyperactivity Disorder.” (16) A link to the Association for Applied Psychophysiology & Biofeedback (AAPB) is also provided. (17) The AAPB rates neurofeedback as efficacious (level 4 on a scale of 1–5 with 5 being the best) for ADHD, based on several small controlled and moderately large clinical studies showing that neurofeedback significantly helps children with ADHD who have problems with mathematics. Guidelines on ADHD from the American Academy of Child and Adolescent Psychiatry in 2007 do not mention neurofeedback. (18) The American Psychiatric Association’s 2006 guidelines on the treatment of panic disorder and substance abuse do not address neurofeedback. (19) No information on neurofeedback was identified on the Web site of the American Psychiatric Association. No information on neurofeedback was identified on the ADHD site of the American Academy of Pediatrics. (20)
References:
- 1997 TEC Assessment; Tab 21
- Fuchs T, Birbaumer N, Lutzenberger W et al. Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: a comparison with methylphenidate. Appl Psychophysiol Biofeedback 2003; 28(1):1-12.
- Thompson L, Thompson M. Neurofeedback combined with training in metacognitive strategies: effectiveness in students with ADD. Appl Psychophysiol Biofeedback 1998; 23(4):243-63.
- Swingle PG. Neurofeedback treatment of pseudoseizure disorder. Biol Psychiatry 1998; 44(11):1196-9.
- Graap K, Freides D. Regarding the database for the Peniston alpha-theta EEG biofeedback protocol. Appl Psychophysiol Biofeedback 1998; 23(4):265-75.
- Egner T, Strawson E, Gruzelier JH. EEG signature and phenomenology of alpha/theta neurofeedback training versus mock feedback. Appl Psychophysiol Biofeedback 2002; 27(4):261-70.
- Heinrich H, Gevensleben H, Strehl U. Annotation: neurofeedback - train your brain to train behaviour. J Child Psychol Psychiatry 2007; 48(1):3-16.
- Monastra VJ, Lynn S, Linden M et al. Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder. Appl Psychophysiol Biofeedback 2005; 30(2):95-114.
- Levesque J, Beauregard M, Mensour B. Effect of neurofeedback training on the neural substrates of selective attention in children with attention-deficit/hyperactivity disorder: a functional magnetic resonance imaging study. Neurosci Lett 2006; 394(3):216-21.
- Drechsler R, Straub M, Doehnert M et al. Controlled evaluation of a neurofeedback training of slow cortical potentials in children with Attention Deficit/Hyperactivity Disorder (ADHD). Behav Brain Funct 2007; 3:35.
- Gevensleben H, Holl B, Albrecht B et al. Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial. J Child Psychol Psychiatry 2009 Jan 12. [Epub ahead of print]
- Scott WC, Kaiser D, Othmer S et al. Effects of an EEG biofeedback protocol on a mixed substance abusing population. Am J Drug Alcohol Abuse 2005; 31(3):455-69.
- Sokhadze TM, Cannon RL, Trudeau DL. EEG biofeedback as a treatment for substance use disorders: review, rating of efficacy, and recommendations for further research. Appl Psychophysiol Biofeedback 2008; 33(1):1-28.
- Angelakis E, Stathopoulou S, Frymiare JL et al. EEG neurofeedback: a brief overview and an example of peak alpha frequency training for cognitive enhancement in the elderly. Clin Neuropsychol 2007; 21(1):110-29.
- Egner T, Strawson E, Gruzelier JH. EEG signature and phenomenology of alpha/theta neurofeedback training versus mock feedback. Appl Psychophysiol Biofeedback 2002; 27(4):261-70.
- American Psychology Association. Getting in touch with your inner brainwaves through biofeedback. Available at: http://www.psychologymatters.org/biofeedback.html. Last viewed May 2009.
- Association for Applied Psychophysiology & Biofeedback Web site. Available at: http://www.aapb.org Last viewed May 2009.
- American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007; 46(7):894-921. Available at: http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf. Last viewed May 2009.
- Kleber HD, Weiss RD, Anton RF et al.; American Psychiatric Association Work Group on Substance Use Disorders. Practice guidelines for the treatment of patients with substance use disorders. Second edition. Available at: http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=SUD2ePG_04-28-06. Last viewed May 2009.
- American Academy of Pediatrics. Parenting Q & A from Understanding ADHD: Information for Parents About Attention-Deficit/Hyperactivity Disorder Available at: http://www.aap.org/pubed/ZZZXL1ITXSC.htm?&sub_cat=18. Last viewed May 2009.
Codes |
Number |
Description |
| CPT | 90875–90876 | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy; code range |
| 90901 | Biofeedback training by any modality | |
| ICD-9 Procedure | 94.39 | Other individual psychotherapy (includes biofeedback) |
| ICD-9 Diagnosis | Investigational for all codes | |
| HCPCS | E0746 | Electromyography (EMG), biofeedback device |
| Type of Service | Medicine; Psychiatry | |
| Place of Service | Outpatient | |
Index
Biofeedback, EEG
EEG biofeedback
Neurofeedback
Policy History
| Date | Action | Reason |
| 01/30/1998 | Add to Medicine section | New policy |
| 07/12/2002 | Replace policy | Policy updated; no change in policy statement |
| 10/09/03 | Replace policy | Policy updated; no change in policy statement |
| 04/1/05 | Replace policy | Policy updated with literature search; reference number 6 added; no change in policy statement |
| 07/20/06 | Replace policy | Policy updated with literature search; no change in policy statement. References numbers 10 and 11 added. E0746 added to code table |
| 09/18/07 | Replace policy |
Policy updated with literature search; reference numbers 13 and 14 added; no change in policy statement. |
| 06/11/09 | Replace policy | Policy updated with literature search; references added and reordered; no change in policy statement. |
Find a Provider
Medicare
Prescription Drugs
Medicare Formulary