Description:
Neurofeedback describes techniques for providing feedback about neuronal activity, as measured by electroencephalogram biofeedback, functional magnetic resonance imaging, or near-infrared spectroscopy, to teach patients to self-regulate brain activity. Neurofeedback may use several techniques in an attempt to normalize unusual patterns of brain function in patients with various psychiatric and central nervous system disorders.

For individuals who have attention-deficit/hyperactivity disorder who receive neurofeedback, the evidence includes randomized controlled trials (RCTs) and a meta-analysis. The relevant outcomes are symptoms, functional outcomes, and quality of life. At least 6 moderately sized RCTs (n range, 90 – 113 patients) have compared neurofeedback with methylphenidate, attention skills training, and/or cognitive therapy. These trials found either small or no benefit of neurofeedback. Studies that used active controls have suggested that, at least part of the effect of neurofeedback may be due to attention skills training, relaxation training, and/or other nonspecific effects. Also, the beneficial effects are more likely to be reported by evaluators unblinded to treatment (parents) than by evaluators blinded (teachers) to treatment, suggesting bias in the nonblinded evaluations. A meta-analysis also found no effect of neurofeedback on objective measures of attention and inhibition. Additional research with blinded evaluation of outcomes is needed to demonstrate an effect of neurofeedback on attention-deficit/hyperactivity disorder. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have disorders other than attention-deficit/hyperactivity disorder (e.g., epilepsy, substance abuse, pediatric brain tumors) who receive neurofeedback, the evidence includes case reports, case series, comparative cohorts, and small RCTs. The relevant outcomes are symptoms, functional outcomes, and quality of life. For these other disorders, including psychiatric, neurologic, and pain syndromes, the evidence is poor, and several questions concerning clinical efficacy remain unanswered. Larger RCTs that include either a sham or active control are needed to evaluate the effect of neurofeedback for these conditions. The evidence is insufficient to determine the effects of the technology on health outcomes.

Background 
Disorders of the Central Nervous System
Various of disorders involve abnormal brain activity, including autism spectrum disorder, insomnia and sleep disorders, learning disabilities, Tourette syndrome, traumatic brain injury, seizure disorders, premenstrual dysphoric disorder, menopausal hot flashes, depression, stress management, panic and anxiety disorders, posttraumatic stress disorder, substance abuse disorders, eating disorders, migraine headaches, stroke, Parkinson disease, fibromyalgia, tinnitus, and attention-deficit/hyperactivity disorder.

Treatment
Neurofeedback is being investigated for the treatment of a variety of disorders. Neurofeedback may be conceptualized as a type of biofeedback that has traditionally used the electroencephalogram (EEG) as a source of feedback data. Neurofeedback differs from established forms of biofeedback in that the information fed back to the patient (via EEG tracings, functional magnetic resonance imaging, near-infrared spectroscopy) is a direct measure of global neuronal activity, or brain state, compared with feedback of the centrally regulated physiologic processes, such as tension of specific muscle groups or skin temperature. The patient may be trained to 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 (SCPs) can regulate cortical excitability and that using the EEG as a measure of central nervous system functioning can help train patients to modify or control their abnormal brain activity. Upregulating or downregulating neural activity with real-time feedback of functional magnetic resonance imaging signals is also being explored. 

Two EEG-training protocols (training of SCPs, theta/beta training) are typically used in children with attention-deficit/hyperactivity disorder. For training of SCPs, surface-negative 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 a 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 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. Neurofeedback protocols for depression focus on alpha interhemispheric asymmetry and theta/beta ratio within the left prefrontal cortex. Neurofeedback for epilepsy has focused on sensorimotor rhythm up-training (increasing 12 – 15 Hz activity at motor strip) or altering SCPs. It has been proposed that learned alterations in EEG patterns in epilepsy are a result of operant conditioning and are not conscious or voluntary. A variety of protocols have been described for treatment of migraine headaches.

Regulatory Status
A number of EEG-feedback systems (EEG hardware and computer software programs) have been cleared for marketing through the 510(k) process. For example, the BrainMaster™ 2E (BrainMaster Technologies) is “indicated for relaxation training using alpha EEG Biofeedback. In the protocol for relaxation, BrainMaster™ provides a visual and/or auditory signal that corresponds to the patient’s increase in alpha activity as an indicator of achieving a state of relaxation.” Although devices used during neurofeedback may be subject to U.S. Food and Drug Administration (FDA) regulation, the process of neurofeedback itself is a procedure, and, therefore, not subject to FDA approval. FDA product codes: HCC, GWQ. 

Related Policies
20127 Biofeedback as a Treatment of Urinary Incontinence in Adults
20129 Biofeedback as a Treatment of Headache
20130 Biofeedback as a Treatment of Chronic Pain
20153 Biofeedback for Miscellaneous Indications
20164 Biofeedback as a Treatment of Fecal Incontinence or Constipation
30103 Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder

Policy:
Neurofeedback is considered investigational and/ or unproven and is therefore considered NOT MEDICALLY NECESSARY.    

Benefit Application
BlueCard/National Account Issues
Neurofeedback may be administered either by a psychiatrist or psychologist.

Rationale
This evidence review was created in January 1998 with searches of the PubMed database. The most recent literature update was performed through April 14, 2022.

Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life, and ability to function, including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, 2 domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent 1 or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Attention-Deficit/Hyperactivity Disorder
Clinical Context and Therapy Purpose
The purpose of neurofeedback is to provide a treatment option that is an alternative to or an improvement on existing therapies, such as behavioral therapy and pharmacologic therapy, in patients with attention-deficit/hyperactivity disorder (ADHD).

The question addressed in this evidence review is: Does neurofeedback reduce symptoms and improve functional outcomes in patients with ADHD?

The following PICO was used to select literature to inform this review.

Population
The relevant population of interest is individuals with ADHD.

Attention deficit hyperactivity disorder manifests in children as symptoms of hyperactivity, impulsivity, and/or inattention, and affects cognitive, academic, behavioral, emotional, and social function.¹ It is one of the most common neurobehavioral disorders of childhood.

Interventions
The therapy being considered is neurofeedback.

Neurofeedback describes techniques for providing feedback about neuronal activity, as measured by electroencephalogram (EEG) biofeedback, functional magnetic resonance imaging, or near-infrared spectroscopy, to teach patients to self-regulate brain activity. Neurofeedback may use several techniques to normalize unusual patterns of brain function in patients with various psychiatric and central nervous system disorders.

Comparators
Guidelines for treatment of ADHD in children and adolescents generally recommend parent training in behavior management, Food and Drug Administration (FDA)-approved medications (e.g., stimulants), and educational interventions. ADHD also occurs in adults, with a prevalence of approximately 3.4% to 4.4% of US adults. Guidelines for the treatment of ADHD in adults include recommendations for psychoeducation, pharmacotherapy, and cognitive behavioral therapy.²

Comparators of interest include behavioral therapy and pharmacologic therapy. Treatment includes support groups, cognitive behavioral therapy, anger management, counseling, psychology, psychoeducation, family therapy, and applied behavior analysis. Medications for treatment include stimulants, cognition-enhancing medication, and antihypertensive drugs.

Outcomes
The general outcomes of interest are symptoms, functional outcomes, and quality of life.

Table 1. Outcomes of Interest for Individuals with ADHD

Outcomes	Details
Symptoms	Outcomes as reported by assessors (parents most-often, or teachers, usually unblinded and with a high risk of bias); Attention Deficit Hyperactivity Disorder-Rating Scale (ADHS-RS, domains of inattention, hyperactivity/impulsiveness, and combined scores); Conners scale; Fremdbeurteilungsbogen für Hyperkinetische Störungen (FBB-HKS) [Timing: greater than 1 year]

ADHD: attention-deficit/hyperactivity disorder.

Table 2. Health Outcome Measures Relevant to ADHD in Children and Adolescents

Outcome	Measure (units)	Description	Clinically Meaningful Difference (If Known)
Attention-Deficit/Hyperactivity Disorder-Rating Scale (ADHD-RS)	Scale from 0 to 54 Higher scores indicate more symptoms 18 items are grouped into 2 subscales: hyperactivity/impulsivity and inattentiveness	Short scale that can be completed by parent, teacher, or investigator based on information provided by teacher or parent	Change between 5.2 and 7.7 points or 30% mean total score change between treatment groups3,
Conners Parent Rating Scale for ADHD	Scale from 0 to 144 Higher scores indicate more symptoms	Used by clinicians and researchers to assess parents' perception of children's behavior in the classroom Assesses conduct problems, learning problems, psychometric problems, impulsivity and hyperactivity, and anxiety	Not defined3,
Conners 3rd Edition-Parent (Conners 3-P)	Scale with 9 subscales Higher scores indicate more symptoms	Used by parents to assess symptoms of ADHD and common comorbid problems	Not defined
Fremdbeurteilungsbogen für Hyperkinetische Störungen (FBB-HKS)	Scale with 20 items Higher scores indicate more symptoms	Items can be rated by parents or teacher	Not defined

ADHD: attention-deficit/hyperactivity disorder.
In studies of neurofeedback, the duration of intervention was at least 1 month and ranged from 1 to 12 months.^4,5,6 Follow-up studies of RCTs that reported longer-term outcomes have reported results at 6 months.^7,8

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.

• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought

• Within each category of study design, studies with larger sample sizes and longer duration were preferred;

• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Reviews with Meta-Analysis
Numerous systematic reviews with meta-analyses have compared neurofeedback versus other treatments for ADHD in children, adolescents, and adults (Tables 3 to 5). ^9,5,6,4,10 Comparators included methylphenidate, biofeedback, cognitive behavioral therapy, cognitive training, or physical activity. The results of these analyses generally demonstrated either small to moderate or no benefit of neurofeedback versus other treatments for ADHD symptoms.

Table 3. Trials Included in Systematic Reviews of Neurofeedback versus Other Treatments for ADHD

Trials	Systematic Reviews
	Cortese et al. (2016)9	Van Doren (2019)5	Yan et al. (2019)6	Lambez et al. (2020)4	Riesco-Matias (2021)10
Linden et al. (1996)	⚫
Li et al. (2001)		⚫
Heinrich et al. (2004)	⚫	⚫		⚫
Klingberg et al. (2005)				⚫
Bauregard et al. (2006)	⚫			⚫	⚫
Zhang et al. (2006)			⚫
Chen et al. (2007)			⚫
Drechsler et al. (2007)				⚫
Kong et al. (2007)			⚫
Chen et al. (2009)			⚫
Gevensleben et al. (2009)	⚫				⚫
Holtmann et al. (2009)	⚫
Ji et al. (2009)			⚫
Zuo et al. (2009)			⚫
Gevensleben et al. (2010)		⚫
Virta et al. (2010)				⚫
Bakhshayesh et al. (2011)	⚫			⚫	⚫
Chen et al (2011)			⚫
Prins et al. (2011)				⚫
Steiner et al. (2011)	⚫			⚫
Chang et al. (2012)				⚫
Fan et al. (2012)			⚫
Zhou et al. (2012)			⚫
Arnold et al. (2013)	⚫	⚫
Li et al. (2013)			⚫		⚫
Meisel et al. (2013)		⚫	⚫
Miranda et al. (2013)				⚫
Ogrim et al. (2013)					⚫
VanDongen et al. (2013)	⚫				⚫
Chang et al. (2014)				⚫
Christiansen et al. (2014)	⚫	⚫
Du et al. (2014)			⚫
Maurizio et al. (2014)	⚫				⚫
Meisel et al. (2014)					⚫
Steiner et al. (2014)	⚫	⚫			⚫
Vollebregt et al. (2014)	⚫
Bink et al. (2015)	⚫	⚫			⚫
Choi et al. (2015)				⚫
Gapin et al. (2015)
Menezes et al. (2015)				⚫
Miranda et al. (2015)
Moreno et al. (2015)			⚫
Salomone et al. (2015)				⚫
Pan et al. (2016)
Yang et al. (2016)			⚫
Duric et al. (2017)		⚫	⚫		⚫
Gelade et al. (2017)		⚫	⚫	⚫
Strehl et al. (2017)					⚫
Tang et al. (2017)			⚫
Gelade et al. (2018)					⚫
Minder et al. (2018)					⚫
Sudnawa et al. (2018)			⚫		⚫
Moreno-Garcia et al. (2019)					⚫

Table 4. Characteristics of Systematic Reviews and Meta-analyses of Neurofeedback for ADHD

Study	Dates	Trials	Participants	N (Range)	Design	Duration
Cortese et al. (2016)9	To Aug. 30, 2015	13	Children and adolescents with ADHD (any subtype) or hyperkinetic disorder	520 (14 to 94)	13 RCTs of neurofeedback vs. other care	Follow-up: 2 to 12 months
Van Doren et al. (2019)5	To Nov. 29, 2017	10	Children and adolescents with a primary diagnosis of ADHD	256 (11 to 41)	10 RCTs of neurofeedback vs. other care	Follow-up: 2 to 12 months
Yan et al. (2019)6	To Aug. 22, 2018	18	Children, adolescents, and adults with ADHD	1535 (13 to 90)	18 RCTs of neurofeedback vs. methylphenidate	Follow-up: 1 to 6 months
Lambez et al. (2020)4	To Dec. 2017	18	Children, adolescents, and adults with ADHD	618 (20 to 76)	18 RCTs of neurofeedback vs. biofeedback, cognitive behavioral therapy, cognitive training, or physical activity	Follow-up: 25 days to 8 months
Riesco-Matias et al. (2021)10	To July 18, 2018	17	Children and adolescents with a primary diagnosis of ADHD	NR	16 RCTs of neurofeedback vs. active and nonactive controls	Follow up: NR

ADHD: attention-deficit/hyperactivity disorder; NR: not reported; RCT: randomized controlled trial.

Table 5. Results of Systematic Reviews and Meta-analyses of Neurofeedback for ADHD

Study	ADHD Total Symptoms	ADHD Inattention Symptoms	ADHD Hyperactivity/Impulsiveness Symptoms	Inhibition
Cortese et al. (2016)9
Total N	13 trials (n = NR)	11 trials (n = NR)	10 trials (n = NR)	NR
Pooled Effect (95% CI)	Parent-reported: SMD, 0.35 (0.11 to 0.59) Teacher-reported: SMD, 0.15 (-0.08 to 0.38)	Parent-reported: SMD, 0.36 (0.09 to 0.63) Teacher-reported: SMD, 0.06 (-0.24 to 0.36)	Parent-reported: SMD, 0.26 (0.08 to 0.43) Teacher-reported: SMD, 0.17 (-0.05 to 0.39)	NR
I2 (p)	41% (.06)	43% (.07)	0% (.8)	NR
Van Doren et al. (2019)5
Total N	NR	11 trials (n = NR)	11 trials (n = NR)	NR
Pooled Effect (95% CI)	NR	SMD, 0.31 (-0.01 to 0.63)	0.32 (0.15 to 0.49)	NR
I2 (p)	NR	70% (.06)	0% (.0003)	NR
Yan et al. (2019)6
Total N	4 trials (n = 228)	4 trials (n = 228)	4 trials (n = 228)	NR
Pooled Effect (95% CI)	SMD, −0.578 (−1.063 to –0.092)	SMD, -0.667 (-1.245 to -0.109)	SMD, -0.474 (-0.860 to 0.088)	NR
I2 (p)	59% (.062)	70% (.019)	38% (.156)	NR
Lambez et al. (2020)4
Total N	NR	NR	NR	6 trials (n = 203)
Pooled Effect (95% CI)	NR	NR	NR	SMD, 0.61 (-3.77 to 4.82)
I2 (p)	NR	NR	NR	0% ( < .05)
Riesco-Matias et al. (2021)10
Total N	NR	Unblinded evaluation: 11 trials (n = 674) Blinded evaluation: 9 trials (n = 573)	Unblinded evaluation:11 trials (n = 674) Blinded evaluation: 9 trials (n = 573)	NR
Pooled Effect (95% CI)	NR	Unblinded evaluation: SMD, -0.33 (-0.56 to -0.10) Blinded evaluation: SMD, -0.25 (-0.45 to -0.04)	Unblinded evaluation: SMD, -0.17 (-0.33 to -0.02) Blinded evaluation: SMD, -0.16 (-0.32 to 0.01)	NR
I2 (p)	NR	Unblinded: 49% (.005) Blinded: 30% (.02)	Unblinded: 0% (.03) Blinded: 0% (.06)	NR

ADHD: attention-deficit/hyperactivity disorder; CI: confidence interval; NR: not reported; SMD: standardized mean difference.

Randomized Controlled Trials Not Included in the Meta-Analyses
Several RCTs not included in the above systematic reviews are described below (Tables 6 to 9).^11,7,12,13 Hasslinger et al. (2022) published a multi-arm, pragmatic, RCT [NCT01841151] in 202 children and adolescents with ADHD (see Table 6 for trial characteristics) that evaluated the efficacy of 2 neurofeedback treatments (slow cortical potential [SCP] and Live Z-score) compared to working-memory training (active comparator) and treatment as usual (passive comparator).¹² The prespecified primary outcome measure¹⁴ was the self-, teacher- and parent-reported assessment of ADHD symptoms post-treatment and at 6 months using the Conners 3rd Edition scale. As only the inattention and hyperactivity/impulsivity Conners subscales were reported by Hasslinger et al., its results are not reported in Table 7. Neither neurofeedback treatment was superior to working-memory training for these outcome measures. Significant differences between SCP and treatment as usual were observed post-treatment for teacher- and parent-rated inattention, with no difference for other outcome measures at either timepoint. A statistically significant difference in Live Z-score over treatment as usual was only observed at the 6-month endpoint for teacher-rated inattention and hyperactivity/impulsivity. No other differences between Live Z-score and treatment as usual were observed. Secondary outcomes in this study included measures of teacher- and parent-rated executive function and self-assessed health-related quality of life using the Behavior Rating of Executive Functions (BRIEF) and KIDSCREEN-27 scales, respectively. There were no consistent differences between neurofeedback interventions and control interventions for these outcomes except for teacher-assessed executive function at 6 months follow-up, which found both neurofeedback interventions superior to working-memory training and treatment as usual. Limitations of this RCT are presented in Tables 8 and 9.

Table 6. Characteristics of RCTs of Neurofeedback in ADHD

Study	Countries	Sites	Dates	Participants	Interventions
Lim et al. (2019)11	Singapore	1	Jan. 2012 to June 2016	Children age 6 to 12 years diagnosed with ADHD	BCI-based neurofeedback attention training vs. untreated waitlist control for 8 weeks followed by BCI-based neurofeedback attention training for 20 weeks
Aggensteiner et al. (2019)7	Germany	NR (multicenter)	Sept. 2009 to Jan. 2013	Children age 7 to 9 years diagnosed with ADHD	SCP-based neurofeedback vs. EMG-based biofeedback
Arnold et al. (2020)15	U.S.	2	NR	Children age 7 to 10 years diagnosed with moderate/severe ADHD and theta/beta ratio ≥ 4.5	Treatment consisted of downtraining theta power and uptraining beta power for 38 active neurofeedback treatments vs. 38 control treatments
Hasslinger et al. (2022)12	Sweden	1	2013 to 2019	Children age 9 to 17 years diagnosed with ADHD	4 arms: SCP neurofeedback, Live Z-score neurofeedback; working-memory training, and treatment as usual
Purper-Ouakil et al. (2022)13	France, Spain, Germany, Belgium, Switzerland	9	Aug. 2016 to Sept. 2017	Children age 7 to 13 years diagnosed with ADHD	At-home personalized neurofeedback training vs. methylphenidate

ADHD: attention-deficit/hyperactivity disorder; BCI: brain-computer interface; EMG: electromyography; NR: not reported; RCT: randomized controlled trial; SCP: slow cortical potential; U.S.: United States.

Table 7. Results of RCTs of Neurofeedback in ADHD

Study	ADHD-RS	FBB-HKS	Conners 3-P
Lim et al. (2019)11
N	172
BCI-based neurofeedback	8 weeks of intervention: 3.5 ± 3.87 20 weeks of intervention: 3.3 ± 5.55 4 weeks post-intervention: 4.7 ± 5.94
Waitlist control	8 weeks of intervention: 1.9 ± 4.42 20 weeks of intervention: 1.4 ± 3.94 4 weeks post-intervention: 2.0 ± 4.26
Difference [Neurofeedback — Control] (95% CI)	8 weeks of intervention: 1.6 points (0.3 to 0.29) 20 weeks of intervention: 2.4 points (1.6 to 3.2) 4 weeks post-intervention: 3.3 points (2.5 to 4.2)
Aggensteiner et al. (2019)7
N	144	144
SCP-based neurofeedback	1.28	1.33
EMG-based biofeedback	1.30	1.38
Difference [Neurofeedback - Control] (95% CI)	NR	-0.04 (-0.27 to 0.14)
Arnold et al. (2020)15
N			144
Neurofeedback			Change from baseline to end of treatment: -0.561 Change from baseline to 13-month follow-up: -0.612
Control (sham neurofeedback)			Change from baseline to end of treatment: -0.557 Change from baseline to 13-month follow-up: -0.524
Between-group difference for change from baseline to end of treatment (95% CI)			0.004 (-0.19 to 0.20)
Between-group difference for change from baseline to 13-month follow-up (95% CI)			0.087 (-0.32 to 0.79)
Purper-Ouakil et al. (2022)13
N	149 (per protocol)
Neurofeedback (day 90 – day 0)	-9.21
Methylphenidate (day 90 – day 0)	-17.3
Mean between-group difference at day 90 (90% CI)	8.09 (5.62 to 10.56)
Noninferiority	Noninferiority of neurofeedback to methylphenidate not demonstrated

ADHD-RS: attention deficit-hyperactivity disorder-rating scale; BCI: brain-computer interface; CI: confidence interval; Conners 3-P: Conners 3rd Edition-Parent; EMG: electromyography; FBB-HKS: Fremdbeurteilungsbogen für Hyperkinetische Störungen; NR: not reported; RCT: randomized controlled trial; SCP: slow cortical potential.

Table 8. Study Relevance Limitations of RCTs of Neurofeedback in ADHD

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of Follow-upe
Lim et al. (2019)11	4. Included patients from a single site in Singapore				1. Follow-up occurred only 4 weeks after intervention
Aggensteiner et al. (2019)7	4. Included patients from Germany
Arnold et al. (2020)15
Hasslinger et al. (2022)12	4. Included patients from a single site in Sweden		1. Treatment as usual was not specifically defined	2. Focused on symptom measures as outcomes, which may not correlate with functioning
Purper-Ouakil et al. (2022)13			2. Absence of sham neurofeedback or another nonactive group 1. Methylphenidate "optimally titrated" but doses not specifically defined		1. Absence of follow-up

ADHD: attention-deficit/hyperactivity disorder; RCT: randomized controlled trial.
The evidence limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
^aPopulation key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^bIntervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4. Not the intervention of interest.
^cComparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^dOutcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^eFollow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 9. Study Design and Conduct Limitations of RCTs of Neurofeedback in ADHD

Study	Allocationa	Blindingb	Selective Reportingc	Data Completenessd	Powere	Statisticalf
Lim et al. (2019)11	3.	1. Patients, parents, and investigators were unblinded; outcome assessors and teachers were blinded
Aggensteiner et al. (2019)7	3.	1. Patients were unblinded; blinding of parents and teachers not reported			1.
Arnold et al. (2020)15
Hasslinger et al. (2022)12		1. Parents were unblinded		1. Missing data, especially for teacher ratings
Purper-Ouakil et al. (2022)13		1. Parents and clinicians were unblinded			1. Sample size calculation done but power not specifically stated	1. Secondary analyses were exploratory only

ADHD: attention-deficit/hyperactivity disorder; RCT: randomized controlled trial.
The evidence limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
^aAllocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
^bBlinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^cSelective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^dData Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^ePower key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference.
^fStatistical key: 1. Analysis is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Analysis is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4. Comparative treatment effects not calculated.

Section Summary: Attention Deficit-Hyperactivity Disorder
Several meta-analyses and 5 additional moderately sized RCTs (n range, 144 to 202 patients) have compared neurofeedback with methylphenidate, biofeedback, cognitive behavioral therapy, cognitive training, or physical activity These studies found either small to moderate or no benefit of neurofeedback, and sustained long-term benefit (e.g., at 6 to 13 months) has not been consistently demonstrated. Studies using active controls have suggested that at least part of the effect of neurofeedback might be due to attention skills training, biofeedback, relaxation training, and/or other nonspecific effects. Two of the RCTs indicated that any beneficial effects were more likely to be reported by evaluators unblinded to treatment (parents), than by evaluators blinded (teachers) to treatment, which would suggest bias in the nonblinded evaluations. Moreover, a meta-analysis found no effect of neurofeedback on objective measures of attention and inhibition. Additional research with blinded evaluation of outcomes is needed to demonstrate the effect of neurofeedback on ADHD.

Disorders Other Than Attention Deficit-Hyperactivity Disorder
Clinical Context and Therapy Purpose
The purpose of neurofeedback is to provide a treatment option that is an alternative to or an improvement on existing therapies, such as behavioral therapy and pharmacologic therapy, in patients with disorders other than ADHD.

The question addressed in this evidence review is: Does neurofeedback reduce symptoms and improve functional outcomes in patients with psychiatric, central nervous system, or pain disorders other than ADHD?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with disorders other than ADHD, including psychiatric, central nervous system, or pain disorders.

Interventions
The therapy being considered is neurofeedback.

Comparators
Comparators of interest include behavioral therapy and pharmacologic therapy.

Outcomes
The general outcomes of interest are symptoms, functional outcomes, and quality of life.

Table 10. Outcomes of Interest for Individuals with Disorders Other than ADHD

Outcomes	Details
Reduction of Symptoms as Observed by Parents and Patients	Attention Switching Task; Impact of Pediatric Epilepsy Scale; PTSD symptoms [Timing: 6 weeks]

ADHD: attention-deficit/hyperactivity disorder; PTSD: post-traumatic stress disorder.

Table 11. Health Outcome Measures Relevant to Disorders other than ADHD

Outcome	Measure (units)	Description	Clinically Meaningful Difference (If Known)
Attention Switching Task	msec Longer duration indicates more symptoms	Computerized task measuring ability to adjust behavior in accordance with changing task goals	Not defined16
Impact of Pediatric Epilepsy Scale	Scale from 0 to 33 Higher scores indicate more symptoms	Questionnaire administered to parent or guardian measuring domains of academic improvement, social adaptation, and self-esteem	Not defined16
PTSD symptoms	Various questionnaires Higher scores indicate more symptoms	Various questionnaires administered to patients measuring the frequency and intensity of PTSD symptoms	Not defined17
Sleep efficiency	Percentage Lower values indicate more symptoms	Measure of percentage of total time in bed spent asleep	Not defined18
Sleep fragmentation	Occurrences Higher values indicate more symptoms	Measure of the number of awakening episodes by polysomnography or patient diary	Not defined18
Total sleep time	Minutes Lower values indicate more symptoms	Measure of time spent asleep among total recording time	Not defined18

ADHD: attention-deficit/hyperactivity disorder; PTSD: post-traumatic stress disorder.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Within each category of study design, studies with larger sample size and longer duration were preferred.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Chronic Insomnia
A systematic review by Melo (2019) included 7 RCTs of biofeedback techniques, including neurofeedback, in the treatment of chronic insomnia.¹⁹ The authors identified conflicting results in comparisons of neurofeedback with other cognitive behavioral therapy techniques, placebo, and no treatment. A majority of outcomes demonstrated no significant differences between comparison groups. A majority of studies had a high risk of bias related to blinding of participants and personnel and incomplete outcome data.

Systematic Review with Meta-Analysis
Table 12. Characteristics of a Systematic Review and Meta-analysis of Neurofeedback for Chronic Insomnia

Study	Dates	Trials	Participants	N (Range)	Design	Duration
Melo et al. (2019)19	To 2019	7	Adults with chronic insomnia	224 (18 to 48)	7 RCTs of biofeedback techniques	10 days to 36 months

RCT: randomized controlled trial.

Table 13. Results of a Systematic Review and Meta-analysis of Neurofeedback for Chronic Insomnia

Study	Total Sleep Time	Sleep Fragmentation	Sleep Efficiency
Melo et al. (2019)19
Total N	2 trials (n = NR)	2 trials (n = NR)	2 trials (n = NR)
Pooled Effect (95% CI)	No significant difference between biofeedback and placebo (effect estimate NR)	Mean difference in number of awakenings, -4.5 (-8.33 to -0.67)	No significant difference between biofeedback and placebo as measured by either polysomnography or sleep diaries (effect estimates NR)
I2 (p)	NR	NR	NR

CI: confidence interval; NR: not reported. 

Epilepsy
An RCT by Morales-Quezada (2019) randomized children with focal epilepsy to sensorimotor rhythm neurofeedback, SCP neurofeedback, or sham neurofeedback for 25 sessions over 5 weeks.16, At the end of the intervention period, only the sensorimotor rhythm neurofeedback group demonstrated significant improvement in the activity switching task and all groups demonstrated significant improvements in quality of life.

Table 14. Characteristics of a Recent RCT of Neurofeedback in Epilepsy

Study	Countries	Sites	Dates	Participants	Interventions
Morales-Quezada et al. (2019)16	Mexico	1	NR	Children and adolescents with focal epilepsy responsive to antiepileptic pharmacotherapy and cognitive difficulties in school	SMR neurofeedback, SCP neurofeedback, or sham neurofeedback over 5 weeks

NR: not reported; SCP: slow cortical potential; RCT: randomized controlled trial; SMR: sensorimotor rhythm.

Table 15. Results of a RCT of Neurofeedback in Epilepsy

Study	Attention Switching Task	Impact of Pediatric Epilepsy Scale
Morales-Quezada et al. (2019)16
N	44	44
SMR neurofeedback	Significant improvement from baseline to postintervention (-757 msec; p = .015) and follow-up (-644; p = .04)	1.5-point change from baseline (p = .002)
SCP neurofeedback	Not significant (effect estimate, NR)	1.9-point change from baseline (p = .001)
Sham neurofeedback	Not significant (effect estimate, NR)	1.3-point change from baseline (p = .006)
Difference [Neurofeedback — Control] (95% CI)	NR	NR

CI: confidence interval; NR: not reported; RCT: randomized controlled trial; SCP: slow cortical potential; SMR: sensorimotor rhythm.

Table 16. Study Relevance Limitations of a RCT of Neurofeedback in Epilepsy

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of Follow-upe
Morales-Quezada et al. (2019)16	4. Included patients from a single site in Mexico

              
RCT: randomized controlled trial.
The evidence limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
^aPopulation key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^bIntervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4. Not the intervention of interest.
^cComparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^dOutcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^eFollow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 17. Study Design and Conduct Limitations of a RCT of Neurofeedback

Study	Allocationa	Blindingb	Selective Reportingc	Data Completenessd	Powere	Statisticalf
Morales-Quezada et al. (2019)16	3.				1.

RCT: randomized controlled trial.
The evidence limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
^aAllocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.
^bBlinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.
^cSelective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^dData Completeness key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).
^ePower key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference.
^fStatistical key: 1. Analysis is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Analysis is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4. Comparative treatment effects not calculated.

Substance Abuse
A systematic review by Sokhadze et al. (2008) of neurofeedback as a treatment for substance abuse disorders described difficulties in assessing the efficacy of neurofeedback and other substance abuse treatments.²⁰ Study shortcomings included a lack of clearly established outcome measures, differing effects of the various drugs, the presence of comorbid conditions, the absence of a criterion standard treatment, and use as an add-on to other behavioral treatment regimens. Reviewers 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. Reviewers also noted that few large-scale studies of neurofeedback in addictive disorders have been reported and that the evidence for alpha-theta training has not been shown to be superior to sham treatment.

Pediatric Brain Tumor Survivors
De Ruiter et al. (2016) reported on a multicenter, triple-blind RCT of neurofeedback in 80 pediatric brain tumor survivors who had cognitive impairments.²¹ The specific neurofeedback module was based on individual EEG, and participants, parents, trainers, and researchers handling the data were blinded to assignment to the active or sham neurofeedback module. At the end of training and 6-month follow-up, there were no significant differences between the neurofeedback and sham feedback groups on the primary outcome measures for cognitive performance, which included attention, processing speed, memory, executive functioning, visuomotor integration, and intelligence.

Post-Traumatic Stress Disorder
A meta-analysis by Steingrimsson (2020) evaluated 4 RCTs of adults with post-traumatic stress disorder (PTSD) treated with neurofeedback.¹⁷ Compared with sham neurofeedback, no treatment or other treatment, neurofeedback was associated with significant improvement in PTSD symptoms. Other primary outcomes were only reported in 1 trial each, and the authors concluded there was uncertainty regarding the ability of neurofeedback to improve PTSD symptoms, self-rated suicidality, executive cognitive functioning, and medication use. All studies were at moderate to high risk for bias, and were assessed as having some indirectness and imprecision.

Table 18. Characteristics of a Systematic Review and Meta-analysis of Neurofeedback for PTSD

tudy	Dates	Trials	Participants	N (Range)	Design	Duration
Steingrimsson et al. (2020)17	To 2019	4	Adults with PTSD	123 (12 to 52)	4 RCTs of EEG-based neurofeedback for PTSD vs. sham neurofeedback, other treatment, or no treatment	Follow-up: 4 weeks to 30 months

 EEG: electroencephalography; PTSD: post-traumatic stress disorder; RCT: randomized controlled trial.

Table 19. Results of a Systematic Review and Meta-analysis of Neurofeedback for PTSD

Study	Self-Harm	PTSD Symptoms
Steingrimsson et al. (2020)17,
Total N	1 trial (n = NR)	4 trials (n = 123)
Pooled Effect (95% CI)	1.4-point improvement with neurofeedback (p = .002)	SMD, 2.3 (-4.37 to -0.24)
I2 (p)	89% (< .0001)	NR

CI: confidence interval; NR: not reported; PTSD: post-traumatic stress disorder; SMD: standardized mean difference.

Other Disorders
Literature searches and a systematic review by Schoenberg et al (2014) assessing biofeedback for psychiatric and neurologic disorders²² have identified small studies (case reports, case series, comparative cohorts, small RCTs) of neurofeedback for the following conditions:

• Anxiety²²

• Asperger syndrome²²

• Autism spectrum disorder^23,24

• Cigarette cravings²⁵

• Chronic pain²⁶

• Cognitive impairment²⁷

• Depression^28,29,30

• Depression, pain, or fatigue in patients with multiple sclerosis³¹

• Depression in alcohol addiction²²

• Dissociative identity disorder²²

• Fall risk³²

• Fibromyalgia^33,34

• Insomnia³⁵

• Headache^36,37

• Lower back pain³⁸

• Multiple sclerosis³⁹

• Overweight and obesity^40,41

• Obsessive-compulsive disorder^42,43

• Parkinson disease^44,45,46

• Schizophrenia^47,48,22,49

• Stroke^50,51

• Tinnitus⁵²

• Tourette syndrome^53,54

Section Summary: Disorders Other Than Attention Deficit-Hyperactivity Disorder
The evidence for neurofeedback in individuals with disorders other than ADHD includes case reports, case series, comparative cohorts, small RCTs, and systematic reviews of these studies. For these disorders, the evidence is poor, and a number of questions regarding clinical efficacy remain unanswered. Larger RCTs that include either a sham or active control are needed to evaluate the effect of neurofeedback for these conditions.

Summary of Evidence
For individuals who have ADHD who receive neurofeedback, the evidence includes RCTs and meta-analyses. Relevant outcomes are symptoms, functional outcomes, and quality of life. Several meta-analyses and at least 5 additional moderately sized RCTs (n range, 144 to 202 patients) have compared neurofeedback with methylphenidate, biofeedback, cognitive behavioral therapy, cognitive training, physical activity, or sham neurofeedback. Collectively, these studies found either small or no benefit of neurofeedback. A meta-analysis also found no effect of neurofeedback on objective measures of attention and inhibition. Studies that used active controls have suggested that at least part of the effect of neurofeedback may be due to attention skills training, relaxation training, and/or other nonspecific effects. Also, the beneficial effects of neurofeedback are more likely to be reported by evaluators unblinded to treatment (parents) than by evaluators blinded to treatment (teachers), suggesting bias in the nonblinded evaluations. Additional research with blinded evaluation of outcomes is needed to demonstrate the effect of neurofeedback on ADHD. However, the completion dates for some registered trials of neurofeedback in ADHD have passed without publication of results, suggesting the potential for publication bias. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have disorders other than ADHD (e.g., chronic insomnia, epilepsy, substance abuse, pediatric brain tumors, and PTSD) who receive neurofeedback, the evidence includes case reports, case series, comparative cohorts, small RCTs, and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and quality of life. For these other disorders, including psychiatric, neurologic, and pain syndromes, the evidence is poor, and several questions concerning clinical efficacy remain unanswered. Larger RCTs that include either a sham or active control are needed to evaluate the effect of neurofeedback for these conditions. However, the completion dates for some registered trials of neurofeedback in disorders other than ADHD have passed without publication of results, suggesting the potential for publication bias. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in ‘Supplemental Information' if they were issued by, or jointly by, a U.S. professional society, an international society with U.S. representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

American Academy of Pediatrics
In 2011, the American Academy of Pediatrics (AAP) published clinical practice guidelines on the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.⁵⁵ The AAP stated that although electroencephalogram (EEG) biofeedback is used clinically, it is not approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD and requires further research. The AAP (2012) revised its position on biofeedback, designating it as a "Level 1 — Best Support" treatment for children with ADHD.⁵⁶ In 2019, the AAP published a guideline update to the 2011 guideline for the treatment of ADHD in children and adolescents.⁵⁷ The guideline states that EEG biofeedback is one of several nonmedication treatments that have either too little evidence to support their recommendation or have little or no benefit.

The AAP (2016), in a clinical report on mind-body therapies in children and youth, stated that research suggests benefits of peripheral forms of biofeedback, including EEG biofeedback (neurofeedback) in ADHD.⁵⁸ The report noted no significant contraindications to the use of biofeedback, with the only barriers potentially being financial in nature. Of note, this clinical report has expired and is under review by the authorship team.

National Institute for Health and Care Excellence
In 2013, NICE issued guidance on management and support of children on the autism spectrum.⁵⁹ The Institute stated that a number of treatments were considered but are not recommended, including neurofeedback.

U.S. Preventive Services Task Force Recommendations
Not applicable.

Ongoing and Unpublished Clinical Trials
Some currently ongoing and unpublished trials that might influence this review are listed in Table 20. The completion date for various registered trials of neurofeedback have passed without publication of results, suggesting the potential for publication bias.

Table 20. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT04220112	Comparing Real-time fMRI Neurofeedback Versus Sham for Altering Limbic and Eating Disturbances in Anorexia Nervosa	47	Sep 2022
NCT04408521	Effect of Long-lasting EEG-Neurofeedback on Attention Control and Impulsivity in Adult Attention-Deficit/Hyperactivity Disorder (ADHD)	48	April 2023
NCT04469335	Comparative Clinical Trial With Double-blind Randomized Sham Control and Additive Treatment Toward Efficacy of Mobile Neurofeedback for ADHD Youth: An Exploratory Study.	165	Dec 2021
Unpublished
NCT04097522	The Effectiveness of Neurofeedback for the Treatment of Chronic Pain	102	Oct 2020
NCT02991781	Multidisciplinary Tools for Improving the Efficacy of Public Prevention Measures Against Smoking	140	Feb 2020
NCT01841151	Does Neurofeedback and Working Memory Training Improve Core Symptoms of ADHD in Children and Adolescents? A Comparative, Randomized and Controlled Study	202	Oct 2020

NCT: national clinical trial.
^a Denotes industry-sponsored or cosponsored trial.

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59. National Institute for Health and Care Excellence. Efficacy of neurofeedback for children in the autism spectrum: a pilot study: management and support [CG170]. 2013; https://www.nice.org.uk/guidance/cg170. Accessed April 13, 2022.
60. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Biofeedback Therapy (30.1). Centers for Medicare & Medicaid Services. Accessed April 13, 2022. https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=41&ncdver=1&bc=AAAAQAAAAAAA&

Coding Section

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 diagnoses
HCPCS
ICD-10-CS (effective 10/01/15)		Investigational for all diagnosis
ICD-10-PCS (effective 10/01/15)		ICD-10-PCS codes arely used for inpatient services
	GZC9ZZZ	Mental health biofeedback, other biofeedback
Type of Service	Medicine; Psychiatry
Place of Service	Outpatient

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

 This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2014 Forward     

02/10/2023	Annual review, no change to policy intent. Updating rationale and references
02/01/2022	Annual review, no change to policy intent. Updating rationale and references.
02/01/2021	Annual review, no change to policy intent. Updating rationale and references.
02/03/2020	Annual review, no change to policy intent. Updating rationale, references and description.
02/21/2019	Annual review, no change to policy intent. Updating background, rationale and references.
01/31/2018	Annual review, no change to policy intent.
02/07/2017	Annual review, no change to policy intent. Updating background, description, rationale and references.
02/02/2016	Annual review, no change to policy intent. Updating background, description, rationale and references. Adding regulatory status.
02/25/2015	Annual review, no change to policy intent. Updated rationale and references. Added coding.
02/21/2014	Annual review, added related policies, benefit application. Updated background, description, rationale and references. No change to policy intent.