Docket: EBSA-2009-0010 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Comment On: EBSA-2009-0010-0001 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Document: EBSA-2009-0010-DRAFT-0094 

Comment on FR Doc # E9-9629 

Submitter Information 

Name: Nancy Wigton, M.A., LPC 

Address: 

Scottsdale, AZ, 85260 

Email: nwig@cox.net 

Organization: Applied Neurotherapy Center 

General Comment 

RE: Comments regarding Regulatory Guidance USCG-2007-27022 page 19157, II B specific 

areas 1 and 4, specifically with reference to the requirement that “the 

treatment limitations (including limits on the frequency of treatment, number of 

visits, days of coverage, or other similar limits on the scope or duration of 

treatment) applicable to such mental health or substance use disorder benefits 

are no more restrictive than the predominant treatment limitations applied to 

substantially all medical and surgical benefits covered by the plan.” 

Introduction 

I am a Licensed Professional Counselor and am also a Biofeedback Certification 

Institute of America Board Certified Neurofeedback Therapist. I have been 

providing Neurofeedback (aka EEG Biofeedback) for 10 years. However, I cannot 

count the number of prospective clients who desperately needed and desired 

Neurofeedback but could not afford this very effective and necessary service 

because their insurance company refused to pay for Neurofeedback. Because of 

this, what I have found is that THOSE WHO NEED NEUROFEEDBACK THE MOST CAN ACCESS 

IT THE LEAST! This is a GROSS injustice and I strongly urge that the MHPAEA be 

implemented in a way to require that Neurofeedback and/or Biofeedback be covered 

in the same way as other medical treatments as provided for in the Act. 

I am a strong advocate of evidence based practice and pursue this in my 

practice. My focus on the importance of evidence based practice has resulted in 

PUBLIC SUBMISSION 

As of: May 26, 2009 

Received: May 25, 2009 

Status: Pending_Post 

Tracking No. 809b41bc 

Comments Due: May 28, 2009

Submission Type: Web
increasing awareness of the minimal evidence base for much of medical surgical 

practice, and of the complete absence of parity between limitations placed on 

mental health and substance abuse treatment in comparison to medical surgical 

treatment allegedly in the name of evidence based practice. 

More restrictive scientific review criteria in mental health and substance abuse 

treatment. 

EEG biofeedback is an approach in several areas of mental health and substance 

abuse treatment that is safe, non-invasive, widely available, and has an ample 

evidence base in over thirty years of clinical practice and hundreds of 

published studies. Like the research supporting cardiovascular treatment, EEG 

biofeedback research includes randomized controlled studies as well as 

non-randomized, open trials and case studies. However, most insurers do not 

cover EEG biofeedback services, usually based on claims of insufficient 

scientific evidence of efficacy of this treatment. This is the case with most 

health insurers active in my geographic area, including Blue Cross Blue Shield 

of Arizona and Aetna Behavioral Health. 

This represents a limitation in coverage in mental health care that is not 

present in medical and surgical benefits, since many medical treatments that are 

routinely covered have substantially less research evidence of efficacy than 

biofeedback. In this way, more restrictive scientific review criteria are 

employed for limiting the coverage of biofeedback in mental and behavioral 

health care than those employed for review of many medical procedures. This 

appears to be a violation of the requirements of parity under MHPAEA. 

According the the January 2005 issue in Child and Adolescent Psychiatric Clinics 

of North America, EEG biofeedback was considered to meet the review criteria as 

a “clinical guideline for treatment of ADHD, seizure disorders, anxiety (eg, 

obsessive-compulsive disorder, GAD, posttraumatic stress disorder, phobias), 

depression, reading disabilities, and addictive disorders. This finding suggests 

that EBF always should be considered as an intervention for these disorders by 

the clinician. “ This review was published in 2005; many additional studies 

demonstrating the efficacy of EEG biofeedback have been published since that 

time. It is without question that there is a substantial research evidence base 

of documenting the effectiveness of this very safe and widely available 

treatment in a range of very difficult to treat mental and behavioral health 

disorders. 

Perhaps more importantly, Neurofeedback/EEG biofeedback shows substantial 

efficacy in many conditions that are quite resistant to treatment by other 

means. For example, seven studies have been completed evaluating the efficacy of 

EEG biofeedback for autism spectrum disorders. All have shown substantial 

benefit in social, emotional, and executive function, in several studies after 

only 20 sessions, or ten weeks of treatment. 

Adequate and practical scientific review criteria The criteria for “gold 

standard” scientific research methods have increasingly and steadily grown 

stricter and more demanding. The result is that it is extraordinarily expensive 

and time consuming to conduct research that meets these strict standards, 

especially mental health and substance abuse treatment 

outcome research. 

While it is a worthy goal that treatment outcome studies attain this gold 

standard for all interventions in use, it simply is not practical. For example, 

many if not most parents of children with autism spectrum disorder recognize the 

importance of scientific research, but simply cannot afford to wait until all 

approaches are thoroughly studied with such rigorous methods. Instead they are 

willing to consider approaches that have preliminary evidence of efficacy as 

long as they are safe and have few adverse effects. 

In using this common sense, these parents are in fact supported by scientific 
evidence. It is a legitimate goal of scientific research to determine 

empirically the type of criteria that are most suitable for use in scientific 

review. The question of what type of research is needed to provide adequate 

empirical support for treatment can be answered using the scientific method. 

Some recent research of this type suggests that the increasing tendency to 

accept as adequate evidence only results from randomized controlled trials 

itself represents an opinion unsupported by the evidence base. 

Recent meta-analyses comparing the results of observational studies versus 

randomized controlled trials to assess efficacy of medical treatment reveal that 

results from the two approaches to research are generally concordant . For 

example, analyzing data from 136 published reports of efficacy of 19 diverse 

medical treatments, Benson and Hartz concluded “In only two of the 19 analyses 

of treatment effects did the combined magnitude of the effect from the 

observational studies lie outside of the 95% confidence interval for the 

combined magnitude in the randomized controlled trials’”. (A comparison of 

observational studies and randomized, controlled trials. N. Engl. J. Med. 

342(25), 1878–1886 (2000). These findings suggest that in most instances, 

observational studies provide adequate data to evaluate treatment outcome. Since 

observational studies are much less costly and time consuming, scientific review 

criteria that are both adequate and practical may accept as valid evidence the 

outcome of less highly controlled observational studies. 

A clear violation of parity and equity. 

Unquestionably, many if not most insurers employ more restrictive and limiting 

scientific review criteria in the evaluation of methods in mental and substance 

abuse treatment than are predominantly employed in medical and surgical 

treatment. The contrast between guidelines in cardiology and restrictions 

against EEG biofeedback is only one example. There are many others, such as 

limitations placed on psychological and neuropsychological assessment for many 

disorders. 

Empirical research suggests that these stricter standards are unnecessarily 

restrictive, since the findings of uncontrolled observational studies are 

generally concordant with findings form more controlled research. However, 

whatever standard is employed for assessing the scientific evidence, parity 

requires that the same standard is employed for mental health and substance 

abuse that is employed for most medical surgical treatments. But this is not in 

fact the case. 

Clearly, with regard to the example of EEG biofeedback, a well studied and safe 

treatment, the treatment limitations applicable to mental health or substance 

use disorder benefits are much more restrictive than the predominant treatment 

limitations applied to medical and surgical benefits covered by most plans. 

Parity requires that the same scientific review criteria be used for coverage of 

mental health and substance disorder treatment that predominate in coverage of 

medical and surgical services. However, for most insurers, EEG biofeedback (aka 

Neurofeedback) is not a covered service, even though there is an empirical 

evidence-base for EEG biofeedback that is far stronger than that for many 

covered medical services. True parity, as envisioned in MHPAEA, will only be 

achieved when regulations require that insurers use the same scientific review 

criteria that are applied for the preponderance of medical and surgical 

treatments in providing and limiting access to mental health and substance abuse 

treatment. By this rule, EEG biofeedback should be covered. 

I strongly urge that you write and enforce regulations that require health 

insurers to use the same scientific review criteria for mental health and 

substance abuse services such as EEG biofeedback or neurofeedback that they use 

for most medical procedures. 

Thank you for your attention to this very important matter. I would be happy to 

provide documentation to support the claims made above about the level of 
evidence supporting EEG biofeedback. 

Sincerely, 

Nancy Wigton, M.A., LPC, BCIA-EEG 

Licensed Professional Counselor 

Board Certified Neurofeedback Therapist