Medicine Section - Neurofeedback

IMPORTANT REMINDER

Regence Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with contract terms. Benefit determinations are based in all cases on the applicable contract language. To the extent there may be any conflict between the Medical Policy and contract language, the contract language takes precedence.

PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that are considered investigational or cosmetic. Providers may bill members for services or procedures that are considered investigational or cosmetic. Providers are encouraged to inform members before rendering such services that the members are likely to be financially responsible for the cost of these services.

Description

Neurofeedback training is a term used to describe the feedback of neural information to patients with certain central nervous system (CNS) disorders in an attempt to teach these patients to modify their brain function. Neurofeedback may be conceptualized as a type of biofeedback that uses the electroencephalogram (EEG) as a source of feedback data. It is hypothesized that using the EEG as a measure of CNS functioning can help train patients to modify or control their brain function in the treatment of a variety of disorders, including attention deficit/hyperactivity (AD/HD) disorder, learning disabilities, seizure disorders, substance abuse-related disorders, menopausal hot flashes, panic and anxiety disorders, substance abuse, depression, stress management, migraine headaches, Tourette’s syndrome, or sleep disorders.

Although related in concept to biofeedback, neurofeedback differs in that the information fed back to the patient, i.e., EEG tracings, is not physiologic in nature.

Policy/Criteria

The use of neurofeedback as a treatment for any disorder is considered investigational.

Position Summary

This policy was initially based on a 1997 BlueCross BlueShield Association Technology Evaluation Center (TEC) assessment (2), which noted that there was inadequate data to permit conclusions regarding the health outcomes 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 two studies used appropriate control conditions.

An updated search of the MEDLINE database through June 7, 2005 did not identify any articles that alter the conclusions of the TEC assessment. Six relevant articles were identified, but none involved randomized, controlled studies in which neurofeedback was used to treat specific conditions. One article consisted of an uncontrolled case series of 111 subjects with panic disorder. (3) The patients received neurofeedback and metacognitive strategies. In most instances, the neurofeedback was used to identify when the subject was focused, thought to be the most optimal time for subsequent metacognitive therapy. The uncontrolled nature of this study prohibits the assessment of the contribution of neurofeedback to the overall treatment effect and prohibits assessment of a possible placebo effect. A second article is a case study of three patients with epilepsy (4), and a third article addressed methodological issues only. (5) A fourth article reported on a randomized controlled trial in which neurofeedback was used for relaxation; Egner and colleagues found that alpha/theta feedback did result in greater theta/alpha ratios as compared to mock feedback, thus suggesting relaxation. (6) However, there was no difference in subjective reports as both groups reported significantly lower levels of activation after training sessions. The fifth article consisted of a comparative study of neurofeedback and methylphenidate therapy in 34 patients with attention deficit disorder. (7) In this nonrandomized study, patients in both groups reported improvements in various measures of attention. Similar results were reported in a nonrandomized study of 61 patients with AD/HD reported by Rossiter. (8) However, several study flaws preclude the ability to reach scientific conclusions concerning the efficacy of neurofeedback in the treatment of AD/HD, namely, 1) patients were allowed to select their own treatment, either home or office neurofeedback or stimulant medications; 2) some of the patients receiving neurofeedback also received stimulant medications, thus introducing a co-intervention; 3) patients were not matched on all of the outcome variables; 4) neurofeedback sessions varied between the office (40 treatment sessions over 3 ½ months) and home settings (60+ treatment sessions over 3 months), so the experimental intervention was inconsistent in the neurofeedback group of 31 patients; and 5) differing testing schedules were used to evaluate the two study groups.

In a June 2005 review/meta-analysis, Monastra and colleagues 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 EEG biofeedback for attention deficit/hyperactivity disorder (ADHD). (9) The authors concluded that EEG biofeedback 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 benefits were reported in the 5 randomized group studies (totaling 214 patients) included in their analysis; however, the ranking for EEG biofeedback for ADHD was based on the need for further studies controlled for patient and therapist factors that could unduly influence outcomes.

In a controlled study of 120 substance abuse patients being treated on an inpatient basis, Scott and colleagues concluded that patients randomized to EEG biofeedback 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 EEG biofeedback sessions (77% vs. 44%, and an average of 135 days vs. 101 days p <0.005). (10) After 46 treatment days, the authors also reported the Test of Variables of Attention (TOVA) significantly improved and 5 of 10 scales of the Minnesota Multiphasic Personality Inventory-2 significantly differed in a positive manner in the EEG biofeedback group. While the authors indicate 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. Therefore, firm conclusions from this study cannot be made, and one trial of 120 patients is not sufficient given the prevalence of this condition.

In 2006, there was continued research interest in the use of neurofeedback in the treatment of ADHD and other cognitive, behavioral and mood disorders.  These newer studies sought to further explain and validate the theoretical basis for the neurofeedback mechanism. (11-15) However, none of the published reviews, case series or clinical studies provide data concerning how the use of neurofeedback effects the health outcomes of the patient.

A review of published guidelines with regard to neurofeedback found The American Psychiatric Association’s guidelines on the treatment of panic disorder and substance abuse do not address neurofeedback. (16) The American Academy of Pediatrics clinical practice guidelines on treatment of children with ADHD does not specifically recommend neurofeedback. (17) Finally, the American Psychological Association Web site briefly discusses neurofeedback but does not specifically make a recommendation for or against it. (18)

An updated search of the MEDLINE database through August 7, 2008 failed to return any articles that alter the conclusions reached above.

References

1. BlueCross BlueShield Association Medical Policy Reference Manual, Policy No. 2.01.28
2. TEC Assessment: Neurofeedback, 1997; BlueCross and BlueShield Association Technology Evaluation Center, Vol 12, Tab 21
3. Thompson L, Thompson M. Neurofeedback combined with training in metacognitive strategies: effectiveness in students with ADD. Appl Psychophysiol Biofeedback 1998;23:243-63
4. Swingle PG. Neurofeedback treatment of pseudoseizure disorder. Biol Psychiatry 1998:44:1196-99
5. Graap K, Freides D. Regarding the database for the Peniston alpha-theta EEG biofeedback protocol. Appl Psychophysiol Biofeedback 1998;23:265-72;273-75
6. 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
7. 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
8. Rossiter T. The effectiveness of neurofeedback and stimulant drugs in treating AD/HD: part II. Replication. Appl Psychophysiol Biofeedback 2004;29(4):233-43
9. 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
10. 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
11. Beauregard M, Lévesque J. Functional magnetic resonance imaging investigation of the effects of neurofeedback training on the neural bases of selective attention and response inhibition in children with attention-deficit/hyperactivity disorder. App Psychphys Biofeed 2006 [Epub ahead of print]
12. Barnea A, Rassis A, Zaidel E. Effect of neurofeedback on hemispheric word recognition. Brain and Cog 2005;59:314-21
13. Raymond J, Varney C, Parkinson L et al. The effects of alpha/theta neurofeedback on personality and mood. Cog Brain Res 2005;23:287-92
14. Lévesque 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. Neuroscience Ltr 2006;394:216-21
15. Hermans D, Soei E, Clarke SD et al. Resting EEG theta activity predicts cognitive performance in attention-deficit hyperactivity disorder.  Pediatr Neuro 2005;32(4):248-56
16. American Psychiatric Association Web site www.psych.org (Verified 08/07/08)
17. American Academy of Pediatrics Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder Pediatrics 2001;108(4):1033-1044 available online at http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B108/4/1033 (Verified  8/18/08)
18. American Psychological Association Web site:  www.apa.org  (Verified 8/18/08)

Cross References

Cognitive Rehabilitation, Regence Medical Policy Manual, Allied Health, Policy No. 20

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