Page 1 of 2 

PUBLIC SUBMISSION 

13ockct: IKS~P09-0008. 

Request for Information for Paul Wellstone and Pete Dorntmici Mcrltal Hcaltl~ Parity and 

Addiction Equity Act of 2008 

Comment On: I KS-2009-0008~Q40l. 

Request fur lnfontlat ion Regarding the Paul Wellstone and Pete Dornenici Mental I Iealth Parity 

and Addiction Equity Act of 200% 

Document: !RS:201)9-0008:UOr?7 

Comment on FR Doc # E9-09629 

Submitter Information 

Name: Betty D Powel! 

Address: 

Wilmington. NC, 

Su hmittcr's Representative: Pra~tict: Administrator 

Organization: A ! l ied Psychophysialogy, PLLC 

General Comment 

1. EL'Sective rules arc nccdcd to address and incorporate the growing recognition 

within the medical wmmuni ty d~at hcal t h promotion is integral1 y linked to 

psychophysiology. 

2. Coverage ru~d authorization of treatment should be based on medical need (as 

bas4 on pruvider j udgmcnt not an irlsurance clerk 01. panel) and provider licensure 

and certification, not some arbitrary rules concuctcd by thc insurance companies. 

3. C'o-pays for rnentnl health should be the same a$ for primary care office visits. 

4. Effective implementation of Mental Hcalth Parity wi l l save healtlicare costs as 

the administrative wsts in navigating coveragc ditTcrcnccs should bc rducd. 

5. 'The insurance companies need to provide parity to mental health providers by 

allowing them to provide the covered services legally within their scc~pc of practicc. 

Medical / surgical providers are not restricted as to what uuvered pru~rxlurcs thcy 

can perform if it is within their legal scope US practice. 

6. The health insurance industry needs tv eliminate thc bias against mcntal health 

orient d procedures and recogni~e biuf'ccdback and nuurnfeedback therapy (CPT 

90901) as a clinically effective intervention Sor thust: illncsscs that that have a tl-nck 
Pagc 2 of 2 

rccorcl of effective use and study through scientific peer review (not an insurance 

panel review). 

7. l..nheling n mental health pmcedure such as biofeedback as "alternative" should 

not allow insurar~cc companies to make it imn~une to ~nental heal tli parity 

regulaliun. 

Attachments 

IRS-200C)-0i?0Si-01!6711. Cornr~lc~lt on FR Doc # E9-09629 
Federal Register 1 Yot. 74, No. 80 I Tuesday, April 28, 2009 1 Proposed Rules 

DEPARTMENT OF THE TREASURY 

Internal Revenue Service 

26 CFR Part 54 

RIN 1545-0170 

DEPARTMENT OF LABOR 

Employee Benefits Security Administration 

29 CFR Part 2590 

RIN 1210-AB30 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare ti Medicaid Services 

45 CFR Parts 144 and 146 

[CMS-4140-NC] 

RIN 0938-AP65 

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

Addiction Equity Act of 2008 

page 19 1 57, 11 B specific areas 1, 2 and 4 

I am the Medical Practice Administrator for a private healthcare practice in North Carolina that 

provides assessments, treatment and care of psychophysiologicat and neuropsychiat ric disorders. The 

owner of the practice is an advanced practice nurse, licensed and nationally board certified as a nurse 

practitioner (to provide primary medical care) and is also a licensed and nationatly board certified 

advance practice nurse clinical specialist in psychiatry and mental heatth. The owner is nationally 

certified (BCIA) in biofeedback and EEG -neurofeedback. Our practice is a unique clinical resource to 

the SE coastal region of North Carolina that enables our clients to obtain treatment and care for 

functional medical and neuropsychiatric disorders that they would otherwise need to travel 100+ miles 

to Duke or UNC Chapel Hill Medical Centers to receive. 

I provide all of the insurance and managed care support for the practice, and I have done so for the 

Iast 3+ years. I have a Master's of Science degree in systems management (which is a blending of 

applied mathematics - operations research - and management science), and I also have lot years 

experience as a former federal regulator. I was retained by the practice to enable them to survive 

financially in the increasingly complex and poorly reimbursed fields of primary care and mental health. 

After three years of severe cost cutting and making tough choices about which insurance plans to 

maintain active in-network contracts, the practice is still not profitable and the owner has continued 

to self-finance and underwrite the practice and has not drawn any income to date. Our continued 

survival to offer this much needed service to our community is in question. Much of this is due to 

disparity in reimbursement for mental health related disorders, confusion and lack of clear 

accountability in insurance policies over the "cross-over diagnoses that are psychophysiological - those 

which have both mental health and medical components to the claims", denials in coverage and refusal 

of payment by insurers, disparity in payment to advanced practice nurses, and lack of recognition by 

insurers of the efficacy of biofeedback and EEG neurofeedback (which is based on a bias against mental 

health procedures). Given my expertise and experience on the "f rontlines" of working with providers 

and insurance companies for both medical and mental health services, I believe 1 am exceptionally well 

quaIified to comment on considerations for this advanced rule. 

First of all, effective rules are needed to address and incorporate the growing rec%nition wlthln 

the medical communfy that health promotion is integrally linked to psychophysiology. 

Psychophysiology is the science of the inter- relationship between mental activity and physical functions 

- in other words, how mental activity affects the body, and how physiological activity affects the mind. 
Appiied psychophysiology is the healthcare specialty which uses this information to enable individuals 

to learn to recognize and control mental processes and physiological functions which may be causing 

health problems. Applied psychophysiological interventions have helped many medical specialties, for 

example, many of our referrah are from cardiolqy practices to heip patients control the medical 

consequences of chronic stress related illnesses. The problem with the viability of our practice is not a 

lack of demand for services, but rather if and how much the services will be reimbursed. 

When I contact a prospective, referred patient, I help them navigate their insurance coverage. This 

seems to be "all over the map". Many plans offer the exact inverse coverage of othe~ plans yet both 

may justify their inclusion and exclusion criteria based on some "current medical review". 

Coverage and authorization of treatment should be based on medical need (as based on provider 

judgment not an insurance clerk or panel) and provider licensure and certification, not some 

arbltrary rules concocted by the insurance companies. This level of examining claims and 

establishing guidelines for medical need, based on my experience, is far more disproportionate on the 

mental health side rather than the medical and is the current insurance industry loophole to avoid 

payment of legitimate claims. 

Here are the coverage oriented questions I must address in obtaining benefits determination for our 

patients: 

1) Is the ~lan in-network? Some out of network plans absolutely refuse to pay any benefits to out of 

network providers offering mental health services (Cigna Behavioral). Some, like United Health, will 

reduce the reimbursement from 90% to 60% or less. This is policy-specific and not necessarily company 

or plan specific. By adding complexity and confusion to the plan types, it's hard to tease out which 

lowered reimbursement may be due to lack of mental health parity versus some other variable. Some 

companies, such as United Heatth, offer "gap" coverage for out of network providers that offer 

specialized medical services. For example, if we receive a referral for biofeedback, we are the only 

practice in the region that features a nationally certified biofeedback professional. This somet imes, 

but not consistently, gives us gap coverage to receive in-network reimbursement rates. When the 

patient diagnosis is medical, we consistently receive gap coverage. When the patient diagnosis is 

mental health, gap coverage is frequently denied. 

2) How does the plan handle office visits for "mental health" versus "medical" diaqnoses? One must 

check to determine differences between how the policy covers therapy (90806, 90807) and health and 

behavior services (961 50-95152)? Are all mental health diagnoses handled the same? Some plans (State 

Employees Plan of NC - BCBS) provide 100% coverage, and impose no Limits to type and number of visits 

based on medical need only, provided the primary diagnosis is medical; and we code the claim using 

the CPT Health and Behavior codes (961 50-961 55). Howwer, the State Plan restricts number and type 

of mental health visits and has much higher co-pays for mental health office visits than medical visits. 

Co-pays for mental health should be the same as for primary care. 

Some plans refuse payment unless there is a "medical diagnosis" and not a primary mental health 

diagnosis (Aetna has refused payment on health and behavior codes, and these have also been rejected 

by Cigna, Cigna Behaviorai Health, United Behavioral Health, United, and others). Some plans get even 

more arcane: Some insurance companies provide reduced coveraqe for what they deem to be the 

"iesser" mental illnesses (anxiety spectrum disorders as opposed to schizophrenia, bipolar or major 

depression). Anthem and CareFirst Blw Cross checks the type of mental health dfugnosfs to determine 

level of reimbursement (major mental health disorders such as depression and bipolar get reimbursed 

at a higher level than the anxiety spectrum disorders including panic disorder and PTSD). 

The permutations in coverage and handling of procedures for specific diagnoses are nearly endless, and 

occupy a huge administrative cost to a practice offering mental health services. Sometimes, more than 

four hours of administrative time is spent on determination of benefits to enable effective coding of a 

claim before the client is ever seen. This is a terrible use of healthcare dollars. Effective 
implementation of Mental Health Parity will save healthcare costs a5 the administrative costs in 

navigating coverage differences should be reduced. 

3) Is nre-authorization needed? Is it needed for all procedure cdes and at what time in the care? Are 

there limitations on what type of licensed hcalthcare professional can deliver these services! Insurance 

policies vary on what is needed for prior authorization. For example, BCBS FEHB requires prior 

approval for office based mental health services, but not for office based medical services. 

Mental health pr-oviders are often further restricted than medical providers and not allowed to perform 

a service (even if it is included in the coverage) if they are not the type of provider specified in the 

policy. For example, Mapllan Behavioral and Cigna Behavioral generally require a psychologist or 

physician to perform all psycholqica( or neuropsychological testing with prior authorization. This 

r-t riction is purely exclusiona~. Scope of practice limits enables advance practice mental health 

nurses to perform psychologicai and neuropsychological testing) yet some insurance company refuse to 

reimburse advance practice nunes for any testing (regardless of licensure or training in the testin9 

procedure). This is not the case with the medical/surgical policy, where the insurance companies 

rarely if ever dictate who can perform the service (as this is implicit on how the provider is licensed 

and his/ her scope of practice.) However, insurance companies dic.tate, on the mental health side, 

what type of provider can do what procedure, and this frequently conflicts with licensed practice 

limits. The most obvious case is with psychological and neuropsychological test ins, incorporated under 

the Legat scope of practice for a nurse clinical specialist in mental health and psychiatry, yet excluded 

for reimbursement by many insurance companies. 

The insurance companies need to provide parlty to mental health providers by allowing them to 

provide the covered servlces legally within their scope of practice. Medical / surgical providers are 

not restricted as to what covered procedures they can perform if it is wlthin thefr legal scope of 

practice. 

4) How many visits are allowed? Some insurance plans li~nit the number of visits - some even ta the 

point of nut allowing clinically tested treatment protocols to be completed. For example, BC BS of NC 

limits treatment of biofeedback to 14 visits per year, even though most standard scientifically peer 

reviewed protocols call for 15- 40 visits for treatment (depending ul-t the intervention). In the NC State 

Employees Plan, medical visits are unlimited but mental health visits usually are capped at 20 per year 

or kss. In the RC BS Federal Employees Plan, mental health visits require pre-authorization by 

Magellan (the mental health carve-out company), and then rquire a care plan submittal and review 

after 6 visits. This bureaucratic hurdle to treatment is not levied for medical interventions. 

The health insurance industry needs to eliminate the bias against mental health oriented 

procedures and recognize biofeedback and neurofeedback therapy (CPT 90901) as a clinically 

effective intervention for those illnesses that that have a track record of effective use and study 

through scientific peer review (not an insurance panel review). 

The situation in navigating the huge differences in patient insurance policies is very problematic for 

providing biofeedback, neurofeedback and related assessment services to clients. Biofeedback (CPT 

90901 ). is a highly clinically effective intervention for many psychophysiolgical disorders, yet the 

payment policies are highly variable. A particularly ironic example of this problem is that Blue Cross 

Blue Shield of NC covers biofeedback therapy for some neuromusculsr diagnoses (medical bias) but 

specially excludes coverage for biofeedback for any psycholqical diagnosis whereas Blue Cross Blue 

Shield of Nebraska will cover biofeedback therapy -- but only for psychological diagnoses. Both cite 

(outdated and non peer reviewed) articles to justify their coverage and exclusions. (I could pravide a 

dozen or more examples of these conflicting definitions of coverage.) BCBS Federal Employee Plan 

excludes biofeedback under the heading "alternative treatment". Biofeedback is an alternative to 

pharmacological treatment, but it is not "alternative" to mainstream medicine. This is a false label 

and poor excuse for exclusion, and this should not be tolerated by the federal government for its 

e~nployees. Does labeling something as "a:ternative" make it immune to mental health parity 
regulation? In defense of the Blue Cross companies, at least they tend to publish their policy 

guidelines. United Health and United Behavioral Health refuse to do this, making the coding and 

claims prKess even more enigmatic and problematic. 

Disorders that can be highly effectively treated using biofeedback or neurofeedback include: anxiety 

spectrum diagnoses (including Generalized Anxiety Disorder, somatoform iltness, panic disorder, PTSD), 

AD/HD, high functioning autism and Asperger's, cognitive brain injury (TBI), depression and adjustment 

disorders, sleep disorders and insomnia, functional medical disorders such as irritable bowel syndrome 

and recurrent - spastic abdominal pain, functional breathing disorders, including hyperventilation 

syndrome, and stress related hypertension, migraine and tension headaches. Many of these disorders 

have a 30+ year of treatment study and use for biofeedback and neurofeedback, yet insurers continue 

to label them investigational to justify denial of coverage. Once again, there is no consensus among 

insurers as to which of these interventions for specific diagnows really is investigational, as many of 

them contradict each other's policies. This determination is best teft to the healthcare professionals 

and the professional societies which provide the ethical framework for intervention. In the case of 

biofeedback and neurofeedbac k, professional societies such as the 15NR and MPB, and national 

independent certification entities such as BClA provide excellent scientifically and peer-refereed 

forums for provider certification and procedure clinical efficacy evaluation. Once again, I find the bias 

against mental / behavioral health interventions is the fundamental underpinning that has limited 

coverage for biofeedback and neurof eedbac k . 

Many insurance companies, including Medicare, NC Medicaid and TRICARE will not reimburse for 

biofeedback services for Mental Health problems as a matter of stated policy. This capriciously denies 

individuals access to a clinically effective intervention and encourages those same individuals to 

embark on other, more risky, less effective or costly interventions for their treatment. I estimate that 

50% or more of our referred patients (who take the step of contacting us for treatment), decline 

following through with treatment because their insurance denies or limits reimbursement for 

biofeedback. Insurance companies also hide behind the label of "investigational" as a blanket means 

to deny coverage. Most all insurance companies refuse to reimburse for neurofeedback for AD/ HD or 

TBI using the "investigational" trump card to deny. Many state in written policy that there is not yet 

sufficient evidence for the efficacy of biofeedback or neurafedback. As such, they are using evidencebased criteria that are far more restrictive for mental health services than the criteria which are used 

for medical/surgical services. There are many routine medical and surgical procedures which have far 

fewer con trolled studies about their efficacy than does biofeedback or neurofeedback. These medical 

and surgical procedures are gener,ally not limited because of concerns about how many controlled 

studies have been performed about them. EEG biofeedback is an empirically validated and widely 

recognized effective non-medication treatment for ADIHD, TBI, a5 well as other conditions. For 

example, there are over 50 studies evaluating the effectiveness of EEG biofeedback in the treatment of 

AD/HD, TBI, Substance Use disorders and Autism. A recent review of this literature concluded "EEG 

biofeedback meets the American Academy of Child and Adolercent Psychiatry criteria for" Clinical 

Guidelines "for treatment of ADHD." This means that EEG biofeedback meets the same criteria as 

rnedication for ti-eatinq ADHD, and that EEG biofeedback "should always be considered as an 

intervention for this disorder by the clinician". This sewice has been denied by North Carolina 

Medicaid, United Behavioral Health, NC Blue Cross, Cigna and Cigna Behavioral Health, Magellan, 

among others. 

Ironically, most clerks and representatives from the insurance industry that I interact with on a daily 

basis claim to have never heard of mental health parity or any laws concerning this. I routinely ask 

each company I deal with for their policies concerning mental health parity, and I have never received 

a singte written statement from any. I can't count how many times the concept of this has been 

literally laughed at by rhe representatives from the insurance industry that I deal with. The federat 

government could set the example of leadership in this arena through refon of FEHB to remove 

restrictions to mental health services, including biofedback, and through reform of Medicare policy 

(albeit out of the xope of this legfslation), for inclusion of biofeedback and neurofeedback by TRICARE 

and the VA system (especially for treatment of PTSD and TBI). 
The bottom line is that coverage and authorization of treatment should be based on provider 

determined medical need (not an insurance clerk or panel) and provider Licensure and independent, 

accepted certification entities, not some arbit raw rules concocted by the insumnce companies. 

Clinical efficacv guidelines for mental health services need to be on paritv with medical guidelines. 

I welcome the opportunity to provide input to you as you refine rules for implementation of this 

historic healthcare regulation, and only hope that practices such as ours survive in the interim until 

such clarity and common sense can be mandated. 

Betty Powell, MSM 

PI-actice Administntor 

Allied Psychophysiology, PLLC 

121 3 Culbreth Drive, Wilmington, NC 28405 

Voice: 910-509-71 15; Fax: 91 0-509-7099 
Federal Register / Vol. 74, No. 80 / Tuesday, April 28, 2009 / Proposed Rules 

DEPARTMENT OF THE TREASURY 

Internal Revenue Service 

26 CFR Part 54 

RIN 1545–BI70 

DEPARTMENT OF LABOR 

Employee Benefits Security Administration 

29 CFR Part 2590 

RIN 1210–AB30 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

45 CFR Parts 144 and 146 

[CMS–4140–NC] 

RIN 0938–AP65 

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

Addiction Equity Act of 2008 

page 19157, II B specific areas 1, 2 and 4 

 

I am the Medical Practice Administrator for a private healthcare practice in North Carolina that 

provides assessments, treatment and care of psychophysiological and neuropsychiatric disorders. The 

owner of the practice is an advanced practice nurse, licensed and nationally board certified as a nurse 

practitioner (to provide primary medical care) and is also a licensed and nationally board certified 

advance practice nurse clinical specialist in psychiatry and mental health. The owner is nationally 

certified (BCIA) in biofeedback and EEG-neurofeedback. Our practice is a unique clinical resource to 

the SE coastal region of North Carolina that enables our clients to obtain treatment and care for 

functional medical and neuropsychiatric disorders that they would otherwise need to travel 100+ miles 

to Duke or UNC Chapel Hill Medical Centers to receive. 

I provide all of the insurance and managed care support for the practice, and I have done so for the 

last 3+ years. I have a Master’s of Science degree in systems management (which is a blending of 

applied mathematics - operations research - and management science), and I also have 10+ years 

experience as a former federal regulator. I was retained by the practice to enable them to survive 

financially in the increasingly complex and poorly reimbursed fields of primary care and mental health. 

After three years of severe cost cutting and making tough choices about which insurance plans to 

maintain active in-network contracts, the practice is still not profitable and the owner has continued 

to self-finance and underwrite the practice and has not drawn any income to date. Our continued 

survival to offer this much needed service to our community is in question. Much of this is due to 

disparity in reimbursement for mental health related disorders, confusion and lack of clear 

accountability in insurance policies over the “cross-over diagnoses that are psychophysiological – those 

which have both mental health and medical components to the claims”, denials in coverage and refusal 

of payment by insurers, disparity in payment to advanced practice nurses, and lack of recognition by 

insurers of the efficacy of biofeedback and EEG neurofeedback (which is based on a bias against mental 

health procedures). Given my expertise and experience on the “frontlines” of working with providers 

and insurance companies for both medical and mental health services, I believe I am exceptionally well 

qualified to comment on considerations for this advanced rule. 

First of all, effective rules are needed to address and incorporate the growing recognition within 

the medical community that health promotion is integrally linked to psychophysiology. 

Psychophysiology is the science of the inter-relationship between mental activity and physical functions 

- in other words, how mental activity affects the body, and how physiological activity affects the mind. 
Applied psychophysiology is the healthcare specialty which uses this information to enable individuals 

to learn to recognize and control mental processes and physiological functions which may be causing 

health problems. Applied psychophysiological interventions have helped many medical specialties, for 

example, many of our referrals are from cardiology practices to help patients control the medical 

consequences of chronic stress related illnesses. The problem with the viability of our practice is not a 

lack of demand for services, but rather if and how much the services will be reimbursed. 

When I contact a prospective, referred patient, I help them navigate their insurance coverage. This 

seems to be “all over the map”. Many plans offer the exact inverse coverage of other plans yet both 

may justify their inclusion and exclusion criteria based on some “current medical review”. 

Coverage and authorization of treatment should be based on medical need (as based on provider 

judgment not an insurance clerk or panel) and provider licensure and certification, not some 

arbitrary rules concocted by the insurance companies. This level of examining claims and 

establishing guidelines for medical need, based on my experience, is far more disproportionate on the 

mental health side rather than the medical and is the current insurance industry loophole to avoid 

payment of legitimate claims. 

Here are the coverage oriented questions I must address in obtaining benefits determination for our 

patients: 

1) Is the plan in-network? Some out of network plans absolutely refuse to pay any benefits to out of 

network providers offering mental health services (Cigna Behavioral). Some, like United Health, will 

reduce the reimbursement from 90% to 60% or less. This is policy-specific and not necessarily company 

or plan specific. By adding complexity and confusion to the plan types, it’s hard to tease out which 

lowered reimbursement may be due to lack of mental health parity versus some other variable. Some 

companies, such as United Health, offer “gap” coverage for out of network providers that offer 

specialized medical services. For example, if we receive a referral for biofeedback, we are the only 

practice in the region that features a nationally certified biofeedback professional. This sometimes, 

but not consistently, gives us gap coverage to receive in-network reimbursement rates. When the 

patient diagnosis is medical, we consistently receive gap coverage. When the patient diagnosis is 

mental health, gap coverage is frequently denied. 

2) How does the plan handle office visits for “mental health” versus “medical” diagnoses? One must 

check to determine differences between how the policy covers therapy (90806, 90807) and health and 

behavior services (96150-95152)? Are all mental health diagnoses handled the same? Some plans (State 

Employees Plan of NC - BCBS) provide 100% coverage, and impose no limits to type and number of visits 

based on medical need only, provided the primary diagnosis is medical; and we code the claim using 

the CPT Health and Behavior codes (96150-96155). However, the State Plan restricts number and type 

of mental health visits and has much higher co-pays for mental health office visits than medical visits. 

Co-pays for mental health should be the same as for primary care.

Some plans refuse payment unless there is a “medical diagnosis” and not a primary mental health 

diagnosis (Aetna has refused payment on health and behavior codes, and these have also been rejected 

by Cigna, Cigna Behavioral Health, United Behavioral Health, United, and others). Some plans get even 

more arcane: Some insurance companies provide reduced coverage for what they deem to be the 

“lesser” mental illnesses (anxiety spectrum disorders as opposed to schizophrenia, bipolar or major 

depression). Anthem and CareFirst Blue Cross checks the type of mental health diagnosis to determine 

level of reimbursement (major mental health disorders such as depression and bipolar get reimbursed 

at a higher level than the anxiety spectrum disorders including panic disorder and PTSD). 

The permutations in coverage and handling of procedures for specific diagnoses are nearly endless, and 

occupy a huge administrative cost to a practice offering mental health services. Sometimes, more than 

four hours of administrative time is spent on determination of benefits to enable effective coding of a 

claim before the client is ever seen. This is a terrible use of healthcare dollars. Effective 
implementation of Mental Health Parity will save healthcare costs as the administrative costs in 

navigating coverage differences should be reduced.

3) Is pre-authorization needed? Is it needed for all procedure codes and at what time in the care? Are 

there limitations on what type of licensed healthcare professional can deliver these services? Insurance 

policies vary on what is needed for prior authorization. For example, BCBS FEHB requires prior 

approval for office based mental health services, but not for office based medical services. 

Mental health providers are often further restricted than medical providers and not allowed to perform 

a service (even if it is included in the coverage) if they are not the type of provider specified in the 

policy. For example, Magellan Behavioral and Cigna Behavioral generally require a psychologist or 

physician to perform all psychological or neuropsychological testing with prior authorization. This 

restriction is purely exclusionary. Scope of practice limits enables advance practice mental health 

nurses to perform psychological and neuropsychological testing) yet some insurance company refuse to 

reimburse advance practice nurses for any testing (regardless of licensure or training in the testing 

procedure). This is not the case with the medical/surgical policy, where the insurance companies 

rarely if ever dictate who can perform the service (as this is implicit on how the provider is licensed 

and his/ her scope of practice.) However, insurance companies dictate, on the mental health side, 

what type of provider can do what procedure, and this frequently conflicts with licensed practice 

limits. The most obvious case is with psychological and neuropsychological testing, incorporated under 

the legal scope of practice for a nurse clinical specialist in mental health and psychiatry, yet excluded 

for reimbursement by many insurance companies. 

The insurance companies need to provide parity to mental health providers by allowing them to 

provide the covered services legally within their scope of practice. Medical / surgical providers are 

not restricted as to what covered procedures they can perform if it is within their legal scope of 

practice. 

4) How many visits are allowed? Some insurance plans limit the number of visits – some even to the 

point of not allowing clinically tested treatment protocols to be completed. For example, BC BS of NC 

limits treatment of biofeedback to 14 visits per year, even though most standard scientifically peer 

reviewed protocols call for 15- 40 visits for treatment (depending on the intervention). In the NC State 

Employees Plan, medical visits are unlimited but mental health visits usually are capped at 20 per year 

or less. In the BC BS Federal Employees Plan, mental health visits require pre-authorization by 

Magellan (the mental health carve-out company), and then require a care plan submittal and review 

after 6 visits. This bureaucratic hurdle to treatment is not levied for medical interventions. 

The health insurance industry needs to eliminate the bias against mental health oriented 

procedures and recognize biofeedback and neurofeedback therapy (CPT 90901) as a clinically 

effective intervention for those illnesses that that have a track record of effective use and study 

through scientific peer review (not an insurance panel review). 

The situation in navigating the huge differences in patient insurance policies is very problematic for 

providing biofeedback, neurofeedback and related assessment services to clients. Biofeedback (CPT 

90901), is a highly clinically effective intervention for many psychophysiological disorders, yet the 

payment policies are highly variable. A particularly ironic example of this problem is that Blue Cross 

Blue Shield of NC covers biofeedback therapy for some neuromuscular diagnoses (medical bias) but 

specially excludes coverage for biofeedback for any psychological diagnosis whereas Blue Cross Blue 

Shield of Nebraska will cover biofeedback therapy -- but only for psychological diagnoses. Both cite 

(outdated and non peer reviewed) articles to justify their coverage and exclusions. (I could provide a 

dozen or more examples of these conflicting definitions of coverage.) BCBS Federal Employee Plan 

excludes biofeedback under the heading “alternative treatment”. Biofeedback is an alternative to 

pharmacological treatment, but it is not “alternative” to mainstream medicine. This is a false label 

and poor excuse for exclusion, and this should not be tolerated by the federal government for its 

employees. Does labeling something as “alternative” make it immune to mental health parity 
regulation? In defense of the Blue Cross companies, at least they tend to publish their policy 

guidelines. United Health and United Behavioral Health refuse to do this, making the coding and 

claims process even more enigmatic and problematic. 

Disorders that can be highly effectively treated using biofeedback or neurofeedback include: anxiety 

spectrum diagnoses (including Generalized Anxiety Disorder, somatoform illness, panic disorder, PTSD), 

AD/HD, high functioning autism and Asperger’s, cognitive brain injury (TBI), depression and adjustment 

disorders, sleep disorders and insomnia, functional medical disorders such as irritable bowel syndrome 

and recurrent - spastic abdominal pain, functional breathing disorders, including hyperventilation 

syndrome, and stress related hypertension, migraine and tension headaches. Many of these disorders 

have a 30+ year of treatment study and use for biofeedback and neurofeedback, yet insurers continue 

to label them investigational to justify denial of coverage. Once again, there is no consensus among 

insurers as to which of these interventions for specific diagnoses really is investigational, as many of 

them contradict each other’s policies. This determination is best left to the healthcare professionals 

and the professional societies which provide the ethical framework for intervention. In the case of 

biofeedback and neurofeedback, professional societies such as the ISNR and AAPB, and national 

independent certification entities such as BCIA provide excellent scientifically and peer-refereed 

forums for provider certification and procedure clinical efficacy evaluation. Once again, I find the bias 

against mental / behavioral health interventions is the fundamental underpinning that has limited 

coverage for biofeedback and neurofeedback. 

Many insurance companies, including Medicare, NC Medicaid and TRICARE will not reimburse for 

biofeedback services for Mental Health problems as a matter of stated policy. This capriciously denies 

individuals access to a clinically effective intervention and encourages those same individuals to 

embark on other, more risky, less effective or costly interventions for their treatment. I estimate that 

50% or more of our referred patients (who take the step of contacting us for treatment), decline 

following through with treatment because their insurance denies or limits reimbursement for 

biofeedback. Insurance companies also hide behind the label of “investigational” as a blanket means 

to deny coverage. Most all insurance companies refuse to reimburse for neurofeedback for AD/HD or 

TBI using the “investigational” trump card to deny. Many state in written policy that there is not yet 

sufficient evidence for the efficacy of biofeedback or neurofeedback. As such, they are using evidencebased criteria that are far more restrictive for mental health services than the criteria which are used 

for medical/surgical services. There are many routine medical and surgical procedures which have far 

fewer controlled studies about their efficacy than does biofeedback or neurofeedback. These medical 

and surgical procedures are generally not limited because of concerns about how many controlled 

studies have been performed about them. EEG biofeedback is an empirically validated and widely 

recognized effective non-medication treatment for AD/HD, TBI, as well as other conditions. For 

example, there are over 50 studies evaluating the effectiveness of EEG biofeedback in the treatment of 

AD/HD, TBI, Substance Use disorders and Autism. A recent review of this 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 

medication for treating ADHD, and that EEG biofeedback “should always be considered as an 

intervention for this disorder by the clinician”. This service has been denied by North Carolina 

Medicaid, United Behavioral Health, NC Blue Cross, Cigna and Cigna Behavioral Health, Magellan, 

among others. 

Ironically, most clerks and representatives from the insurance industry that I interact with on a daily 

basis claim to have never heard of mental health parity or any laws concerning this. I routinely ask 

each company I deal with for their policies concerning mental health parity, and I have never received 

a single written statement from any. I can’t count how many times the concept of this has been 

literally laughed at by the representatives from the insurance industry that I deal with. The federal 

government could set the example of leadership in this arena through reform of FEHB to remove 

restrictions to mental health services, including biofeedback, and through reform of Medicare policy 

(albeit out of the scope of this legislation), for inclusion of biofeedback and neurofeedback by TRICARE 

and the VA system (especially for treatment of PTSD and TBI). 
The bottom line is that coverage and authorization of treatment should be based on provider 

determined medical need (not an insurance clerk or panel) and provider licensure and independent, 

accepted certification entities, not some arbitrary rules concocted by the insurance companies. 

Clinical efficacy guidelines for mental health services need to be on parity with medical guidelines.

I welcome the opportunity to provide input to you as you refine rules for implementation of this 

historic healthcare regulation, and only hope that practices such as ours survive in the interim until 

such clarity and common sense can be mandated. 

Betty Powell, MSSM 

Practice Administrator 

Allied Psychophysiology, PLLC 

1213 Culbreth Drive, Wilmington, NC 28405 

Voice: 910-509-7115; Fax: 910-509-7099 

www.alliedpsych.com