From: Maryleeesty@aol.com [mailto:Maryleeesty@aol.com] 

Sent: Monday, May 25, 2009 11:48 AM 

To: EBSA, E-OHPSCA - EBSA 

Subject: Reg Guidance USCG-2007-27022

Comments regarding Regulatory Guidance USCG-2007-27022 

Page 19157, II B specific areas 1 and 4

I am a social worker licensed in Maryland, Washington DC, and Hawaii, who provides EEG 

biofeedback treatment (Neurofeedback) to individuals with Traumatic Brain Injury (TBI), Post 

Traumatic Stress Disorder (PTSD), Attention Deficit Hyperactivity Disorder (ADHD) and mood 

disorders. Over the last 40 years the body of Neurofeedback/biofeedback (NFBF) research has 

validated and continues to document its application as an effective non-medication treatment for 

ADHD, TBI, PTSD, autism, depression and other mood disorders. It addresses basic neurological 

functioning making it applicable to a wide variety of diagnostic categories. 

President Obama is stressing the need for preventive health care practices. NFBF are prime 

examples of therapies that are preventive of development of chronic conditions by teaching 

people skills that build life style changes. If only for this reason alone NFBF should be covered 

by insurance on equal footing with medication and medical/surgical treatments. But there are a 

number of other reasons for parity for NFBF insurance parity. 

Clinical empirical results for use of NFBF are growing exponentially. I conducted a peerreviewed, NIH-funded study of Neurofeedback for TBI that is published in the leading journal for 

head injury (The Jrl. of Head Trauma Rehabilitation, 2001). The state of Texas now mandates 

that Neurofeedback be covered by insurance for TBI. In another NIH-funded study by the 

Oregon Health Sciences University, and a privately funded study I did with Rush-PresbyterianSt.Luke’s Medical Center in Chicago, IL, symptoms of fibromyalgia were found to be 

ameliorated by Neurofeedback. 

The Jrl. of Neuropsychiatry and Clinical Neurosciences is publishing preliminary research results 

of a Neurofeedback treatment with Iraq/Afghanistan soldiers with TBI & PTSD in a study I am 

conducting now in Bethesda, MD. The Journal of Pain has published results on pain reduction in 

soldiers in this same study (The Jrl. of Pain 10_S18, 2009). Every soldier in this study who had 

chronic headache experienced either complete elimination of headache or significant reduction. 

One soldier in the study, a medic, says, “In my opinion every soldier returning from combat 

should receive this treatment whether he thinks he needs it or not.” Walter Reed Army Medical 

Center therapists had me present these study results to them after seeing the positive response to 

Neurofeedback in their soldiers, and DOD is pursuing more research in order to enhance their 

treatment of TBI/PTSD. There is no medication for TBI and traditional treatments have limited 

success. 

Reduction or elimination of medication is almost an expected outcome of Neurofeedback 

treatment. This reduces medical costs, a benefit to society at large. Even with the substantial, and 

growing, body of evidence of the effectiveness of Neurofeedback this common outcome, 

medication reduction cannot be over emphasized. Unlike medications Neurofeedback has few and 

transitory side effects. This one positive contribution of NFBF alone should be compelling to all 

people, but there is one professional body that sees this as a threat - the pharmaceutical industry. 

Six years ago NFBF treatment of a BCBS policy holder client of mine saved BCBS more than her 

average annual medication cost for one year. She was able to eliminate several medications that 

had been covered by BCBS before her treatment with NFBF. A BCBS physician panel, in face-
to-face review, refused to cover the treatment cost that was actually less than the savings already 

enjoyed by BCBS in medication reduction as a result of her treatment. This is only one example 

of lack of understanding of the effectiveness of NFBF. 

A national group for parents of ADHD children (CHADD) is supported by pharmaceutical firms. 

Members of this group have recently begun to recognize that there is an acceptable alternative to 

medication for children, NFBF that does not produce serious side-effects. A recent review of 

ADHD literature concluded “EEG biofeedback meets the American Academy of Child and 

Adolescent Psychiatry criteria for” Clinical Guidelines “for treatment of ADHD.” This means 

that EEG biofeedback meets the same criteria as to medication for treating ADHD, and that EEG 

biofeedback “should always be considered as an intervention for this disorder by the clinician”. 

This service coverage has been denied to my clients by Aetna, United Behavioral Health, Blue 

Cross/Blue Shield, Cigna, and others. This is an unjustified limitation of an effective and 

validated treatment for mental health problems. There are two common reasons given by the 

insurance companies for denials: 1) our company does not cover NFBF for Mental Health 

problems or 2) NFBF is considered experimental. They are using evidence-based criteria more 

restrictive for mental health services than those used for medications or medical services. There 

are many medications,and routine medical procedures which have far fewer controlled studies 

about their efficacy than does NFBF. Medical and surgical procedures are generally not limited 

based upon the number of their controlled studies. 

The parity regulations should require that plans pay for the same range and scope of services for 

Behavioral Treatments as they do for medical and surgical benefits and that a plan cannot be 

more restrictive in their managed care criteria and reviews for mental health disorders when 

compared to medical. To do otherwise violates the intent of the parity concept. New regulations 

should clarify and provide support new guidelines that recognize the new reality in treatment 

options. 

In 2001 the State of Texas Legislature mandated (HB 1626) that Neurofeedback must be covered 

by insurance companies for TBI and its sequelae, (depression, anxiety, and cognitive deficits). It 

is especially interesting in that TBI is often the trigger for depression, ADHD, and is definitely 

involved in development of chronic PTSD, as documented in recent Walter Reed research with 

our Iraq/Afghanistan veterans. Despite this in April, Blue Cross of Texas declared that 

biofeedback and Neurofeedback were “experimental” and “not medically necessary” for all 

conditions except acquired brain injury. First, this is a self-serving move that should not be 

allowed to stand, and second, it is definitely against the interest of the insurance company itself 

because Neurofeedback and biofeedback actually save them money. 

Please support parity because NFBF therapies will actually save insurance companies money, 

reduce medical costs, reduce repeat medical office visits, and promotes health. At its best it is 

preventive care because it prevents the progression into chronic conditions. This serves three 

fronts, the insurance company, their policy holders, and society at large. 

Sincerely, 

Mary Lee Esty, LCSW-C, PhD

7920 Norfolk Ave. 

#200 

Bethesda, MD, 20814 

301-652-7175 
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