Recap of Today's ISNR Discussion Group - Insurance Companies Still Consider NFB Experimental

[Susan Alvarez]

Dear members,

In today's discussion group, we hit on the topic of insurance companies view of neurofeedback. (All members may join the discussion groups at no cost and without registering.)  Rob Longo did a quick query of AI and came back with this response, just for your information:

Asked of AI: Does the health insurance industry still consider neurofeedback as experimental

Short answer:
👉 Yes—most major U.S. health insurers still classify neurofeedback as “experimental” or “investigational” in 2026, although there are some exceptions and gradual changes.

---

What insurance companies currently say (2025–2026)

1) Many major insurers still label it experimental

• Policies from large insurers (e.g., Blue Cross, Cigna, Aetna in some cases) commonly state that neurofeedback/EEG biofeedback is “experimental, investigational, or unproven.” [scienceinsights.org]
• Example: A Blue Cross medical policy explicitly states neurofeedback is**“experimental/investigational” due to insufficient evidence of improved outcomes.** [bcbsm.com]
• Because of that classification, claims are often denied by default.

👉 This “experimental” label is the main reason coverage is limited—not necessarily because there is no research, but because insurers judge the evidence as not strong or consistent enough.

---

2) Medicare and many public plans are especially restrictive

• Medicare generally does NOT cover neurofeedback for mental health or cognitive conditions, classifying it as investigational and not “reasonable and necessary.” [biologyinsights.com]
• It typically only covers traditional biofeedback (not brain-based) for specific physical uses like muscle rehabilitation. [legalclarity.org]

---

3) Industry-wide pattern today

From multiple sources, a consistent pattern emerges:

• ✅ Covered more often:
• Traditional biofeedback (muscle/physiological)
• ❌ Often denied:
• Neurofeedback (EEG-based brain training), especially for
• ADHD
• anxiety
• depression
• PTSD
• Overall:
• “Most major insurers still classify neurofeedback as experimental or investigational.” [neurolaunch.com]

---

But coverage is not zero—there are exceptions

Even though it’s often labeled experimental:

• Some insurers approve it case-by-case (especially with strong documentation)
• Coverage is more likely if:
• Other treatments have failed
• It’s combined with psychotherapy
• It’s billed under broader biofeedback or mental health codes
• Certain plans (or states/employers) do allow reimbursement, but not as a standard benefit [legalclarity.org]

👉 In other words:
“Experimental” doesn’t always mean “never covered”—it usually means “not routinely covered.”

---

Why insurers still call it experimental

Insurers typically use that label when:

• Evidence is considered inconsistent, evolving, or not definitive
• There’s no broad clinical consensus on protocols or outcomes
• It’s not yet widely accepted as a standard first-line treatment

(Some newer research is stronger—especially for ADHD and PTSD—but policy updates tend to lag behind research.)

---

Bottom line

• ✅ Yes — The health insurance industry largely still considers neurofeedback experimental/investigational in 2026
• ❗ This leads to frequent denial of coverage
• 🔄 But:
• Coverage is increasing slowly
• Some plans approve it under specific conditions
• Appeals and documentation can sometimes succeed

Best regards,

 

Susan Alvarez

Executive Director, ISNR

International Society for

   Neuroregulation and Research

2146 Roswell Road

Suite 108, PMB 736

Marietta, GA 30062
Office:  (703) 848-1994
off...@isnr.org

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[Mark Trullinger]

Hello,

This is a good idea, but a few things are not quite right.  Medical policies are not the same as coverage policies.  For example, many BCBS plans do pay for neurofeedback routinely even though it is considered "experimental" or "investigational."  At the end of the day, payment is not always determined by medical policy as lack of payment can lead to consequences with mental health parity and with employers in ERISA plans who want it to be covered and share responsibility for determinations.  While this is a hurdle, one that we are working on and the new CPT codes will help with, it is not something we should just accept.  Moreover, the AMA and most member societies state that there should not be blanket denial of a Category I CPT code in coverage policies for Experimental/Investigational or not medically necessary as they say it has shown that it is not experimental/investigational and is medically necessary for at least one diagnosed condition by meeting the requirements for a Category I CPT code.  

I just want to make sure we don't send the message in a way that this type of behavior of Experimental/Investigational and not medically necessary for anything is acceptable and just how things are.  It is wrong.  And, that is not just me speaking or our field.  We have the majority of medicine that backs that viewpoint.  We need to push back rather than accept and move on. 

Also, there are a number of medicaid plans and the VA that provide coverage.  How can some determine coverage and others not with the same evidence?  How can blanket denials be accepted when there are inconsistencies?  And, generally speaking blanket denials are not acceptable for mental health parity reasons.  These are the questions and actions we need to focus on.

The medicare issue is no longer "experimental" or "investigational" status.  It changed a few years ago.  It is currently "not medically necessary" for the treatment of any "diagnosed condition."  

Best,

Mark

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[sarahprinsloophd]

We now have randomized controlled trials, placebo‑controlled trials, dosage‑finding studies, and mechanistic trials for neurofeedback. In other words, the field has produced all of the evidence, and in some cases more, that pharmaceutical and device manufacturers must generate to achieve formal approval. Yet the pathway for neurofeedback remains unclear and disproportionately difficult.

I’ve read about the extensive work being done around CPT codes, and it’s impressive. But it also raises the question: what else can be done, and why does the bar seem so much higher for neurofeedback than for other neuromodulation approaches?

Take TMS as an example. It is currently one U.S.-based RCT, approximately 129 participants, away from being endorsed as a treatment for pain. Only a small number of European trials have demonstrated TMS efficacy for pain, yet the FDA’s requirement is simply that a single RCT be conducted domestically. That’s a remarkably streamlined path compared to what is being asked of neurofeedback.

So why the apparent leniency for TMS and the barriers for NFB? Is it because TMS already holds FDA clearance for depression, and pain is considered an extension into a new indication rather than a new technology? Or is it because, outside of research settings, TMS must be administered under the supervision of an MD, which may make regulators more comfortable with perceived oversight and risk management?

These discrepancies raise important questions about how neuromodulation technologies are evaluated, who gets to define “acceptable evidence,” and what structural factors influence regulatory momentum.

BTW, the n=129 was recommended by the FDA...

Hope everyone is well!  Have a great weekend.

Warmly,

Sarah

[David Cantor]

Hi Sarah,

Thank you for providing further discussion on this topic.

Personally, I think the discrepancy exists because TMS requires an MD to approve and sign off on the procedure. This implies a very specific licensed discipline is required, under the presumption that a State Board of Examiners provides oversight. For example, while I might recommend TMS for one of my patients, I cannot perform the procedure and expect reimbursement because my Board of Examiners may not consider it within my license’s scope of practice.It is similar for neurofeedback, i.e.,   they don’t explicitly say I cannot do it but it highlights the lack of clear oversight. Theoretically, if someone is certified and using such techniques under their professional scope of practice, it should be covered; however, insurance companies choose not to do so by labeling it "experimental."

The same argument can be made for EMDR. While the body of evidence is relatively limited, because it is coded under psychotherapy, it is generally approved. In many cases, insurance companies lump together any procedure using "sensors" as not being psychotherapy, making the codes arguable.

I have been able to successfully defend getting paid for qEEG examinations by obtaining approval from the Board of Examiners in three states where I have been licensed. They confirmed the procedure is within my scope of practice as a licensed psychologist when used appropriately. Consequently, qEEG is not considered experimental in the same sense as neurofeedback. Perhaps the lack of consensus or definitive oversight from Boards of Examiners regarding neurofeedback remains a significant barrier?

Ultimately, these are my impressions regarding these obstacles, aside from the fact that insurance companies are always looking for excuses to avoid paying for procedures whenever possible.

Best,

Dave

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/2f284800-39a1-4e24-8d6b-5550580146e3n%40googlegroups.com.

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[lrob...@gmail.com]

Dave, Sarah, Mark, and others:

 

My primary concern and reason for posting this is: as people turn more and more to AI… this may discourage the general public from considering neurofeedback because they are not thinking at the level we as professionals do… they simply read: “Policies from large insurers (e.g., Blue Cross, Cigna, Aetna in some cases) commonly state that neurofeedback/EEG biofeedback is “experimental, investigational, or unproven.”

 

We need to begin to address this issue for the general public.

 

Rob

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/CAA6yvVYsHrb5nB6yZmQdA2V1uzdrrUY2KL93%3Dsv9Npgr8ifu2w%40mail.gmail.com.

[David Cantor]

We got the House of Representative in the Georgia Government to pass a resul;tion to have 2  months of every year starting in 2026 going forard - to have as Neurofeedbck Months - we aer planning to leverage this by offering a discussion on talk shows and podcasts  - 

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/002401dceaad%2425559600%247000c200%24%40gmail.com.

[Mark Trullinger]

Rob and all,

Thank you for sending this and for keeping this conversation moving. I think Rob’s concern is important because the general public is not reading these issues the way we do as professionals. They are seeing a simple message: large insurers still call neurofeedback experimental, investigational, or unproven. For many people, especially as they increasingly turn to AI for quick answers, that may be enough to discourage them from considering neurofeedback at all. That is a problem we need to address directly.

In my dissertation, I looked closely at why neurofeedback has not progressed along a typical adoption trajectory for a medical device innovation in mental healthcare. That context matters. Medical device innovations in mental healthcare generally move much more slowly than medications, with an average path closer to 40 years compared to roughly 10 years for a pharmaceutical treatment. When I first studied this, I framed neurofeedback’s under-adoption in comparison to TMS, which appeared to be following a more typical trajectory and perhaps even moving slightly ahead of schedule. It is hard to believe I was collecting those data almost 10 years ago, around the same time I became involved with the CPT project and insurance reimbursement.

At the same time, I do not think the comparison to TMS is always completely fair. There are important differences in how the two fields developed, how they are regulated, and how they are used. Neurofeedback has been around for many years and has had Category I CPT codes since 1978, under the original biofeedback codes that were intended to broadly cover medicine. However, our field also has a complicated history. We have sometimes over-promised what neurofeedback can do, rapidly adopted new protocols and new indications before developing strong internal consensus (within our field before even addressing outside of our field with mainstream medicine), allowed use across a very wide range of professionals and settings, and blurred the boundary between clinical treatment and non-clinical peak performance work. There has also been a longstanding countercultural element in parts of the field that did not want to be part of mainstream medicine and, at times, actively pushed back against it.

I am not saying this describes the whole field, and I am not raising these points simply as criticisms. Some of these qualities are also part of what made neurofeedback innovative, flexible, and clinically meaningful. But all of them slow the path toward mainstream medical acceptance. They make it easier for insurers, regulators, and medical policy committees to say the field lacks standardization, lacks oversight, or lacks consensus, even when the evidence base itself is much stronger than those labels suggest.

This is where the FDA issue becomes especially important. Relatively little formal FDA work has been completed in neurofeedback, and I do not think that is because the bar is impossibly high. I think it is partly because we have not consistently prioritized fitting into the structures mainstream medicine actually uses. Too often, we have wanted to define the rules ourselves rather than ask what the FDA, CPT, insurers, and medical policy committees are actually requiring.

Sarah’s point about TMS is a good example. TMS reportedly had an FDA-recommended pathway involving one U.S.-based randomized controlled trial of approximately 129 participants for pain. That is not an impossible number. More importantly, neurofeedback already has an example within our own broader space. How many people in our field are aware that there is already FDA clearance for a neurofeedback-based device to assist in the treatment of PTSD? That clearance was based on just over 80 participants, included a 3-month follow-up, required a defined amount of improvement in at least 50% of participants, and did not require a control group. This device came from and mostly exists outside of the main frameworks of our field as we currently exist.  That should be concerning.  Moreover, some biofeedback devices with specific indications have also received clearance by relying on existing research, including research involving different devices. So, while a primary indication would likely require more, the starting point is not nearly as unrealistic as many in our field assume.

That is why I think the FDA issue is not simply a research problem. It is a prioritization problem. It is not that we have no evidence. As Sarah stated well, the field has randomized controlled trials, placebo-controlled trials, dosage-finding studies, mechanistic studies, and decades of clinical work. The problem is that the evidence has not always been organized, framed, and operationalized in the way mainstream medicine expects. We have not created a clear blueprint that says: here is the indication, here is the protocol, here is the patient population, here is the outcome measure, here is the dosage, here is the follow-up period, and here is the path to regulatory and reimbursement acceptance.

Rob’s prior terminology crosswalk is a perfect example of this same problem. We use terms like home training, remote training, and telehealth in ways that do not map neatly onto the language used by the FDA, CPT, and mainstream medicine. We could choose to adopt common medical terminology, but instead we often keep translating between our language and theirs. That may seem small, but it affects research design, advertising, documentation, regulatory strategy, and reimbursement. If we cannot even agree to use the language of medicine when speaking to medicine, then we should not be surprised when medicine struggles to understand what we are doing.

The CPT project is a major step in the right direction. While I cannot share confidential details, I do want to say clearly that people with access to that information can verify that, over the last 10 years, there were multiple points when we faced a very real risk of losing our current Category I CPT codes. That would not have been a small setback. It could have moved the field significantly backward and made recovery very difficult if not impossible. We survived that process, and now we have an opportunity to use our presence in the CPT world to move toward medical policy development, reimbursement progress, and broader acceptance by mainstream medicine.

But we need to decide what we actually want as a field. Do we want mainstream acceptance? If so, are we willing to do what that requires? Are we willing to invest in FDA strategy, CPT maintenance, medical policy work, research organization, and terminology alignment? Are we willing to accept that initial coverage may be limited to a few indications and may require more established protocols before broader flexibility is possible? Are we willing to take an honest look at ourselves, including the criticisms that may be uncomfortable but sometimes valid?

Based on my research, my work with insurance companies and CPT, and conversations within medicine more broadly, I think several steps would move us forward.

First, FDA strategy needs to become a real priority. FDA clearance gives us a stronger position for marketing, reimbursement, policy advocacy, and public credibility. The path is not as impossible as we sometimes make it sound. The PTSD neurofeedback device clearance and existing biofeedback device pathways suggest there are realistic starting points if manufacturers and professional organizations choose to prioritize them.

Second, we need to continue investing in CPT work. We now have a presence in that world, not only to protect what we have, but to help shape the field in accepted medical terminology. The last 10 years came with real costs, although we worked hard to keep those costs much lower than what other organizations have had to spend. But if we disappear from that process again, history will likely repeat itself.

Third, we need a better research translation strategy. The issue is not simply that we need more research or a different kind of research. The issue is how the research is framed. We need ISNR, perhaps in coordination with FNNR, to develop a regularly updated research review that places neurofeedback in context with other accepted interventions, identifies where the evidence is strongest, and provides a practical blueprint for moving the field forward. This could function as a living white paper, updated every few years, and could lead to periodic published summaries.

Fourth, we need to keep pushing insurance conversations forward. Medical policies are not the same as coverage policies, and we should not accept blanket denials as if they are simply the natural order of things. Some Medicaid plans, VA systems, employer-funded plans, and private plans do cover neurofeedback under certain conditions. That inconsistency matters. If some systems can determine coverage using the same evidence, then blanket denial by others deserves to be challenged. Mental health parity also matters here, especially when Category I CPT codes are denied across the board as experimental, investigational, or not medically necessary for any diagnosed condition.

I do think we are closer than we have been in a long time. We may be on the edge of meaningful reimbursement progress, possibly even broader coverage in some areas. But that progress will likely come first for a limited number of conditions and may initially require more established protocols. The question is whether we can accept that as a starting point while continuing to make room for the broader clinical flexibility that has always been part of this field.

I appreciate everyone engaging in this conversation, and I hope we continue it. More than that, I hope we act on it. If mainstream acceptance is truly what we want, then we need to fund it, organize around it, speak the language required for it, go through the steps that are commonly accepted like FDA, and build the regulatory and research pathways that make it possible with clear intent and motivation.

Talk is important, desires matter, but at the end of the day intentional targeted action and perseverance until it is complete is what ultimately reveals our priorities.  

So, what do we want?

Best,

Mark Trullinger, PhD

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/002401dceaad%2425559600%247000c200%24%40gmail.com.

[Robert Thatcher]

For those interested, Neuroguide QEEG and Neurofeedback software has been FDA-510K approved since July 2003.   Also, we are commonly audited with a FDA representative coming to our offices every year or two.  

Here is a webpage that gives a partial listing of institutions, including Military and VA Hospitals using FDA registered Neuroguides.  We just received another order for three more Neuroguide systems from Fort Campbell in Kentucky who are now using six Neuroguides to help injured soldiers.

Here is a partial list of FDA registered users of Neuroguide:  https://appliedneuroscience.com/ng-universities-and-institutions/

Robert W. Thatcher, Ph.D.

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/CALktnyAZpUncEbjcnjuGXwmfGBbJxUrdxeon%3D-0LCQsOUzp-bQ%40mail.gmail.com.

[John Mekrut]

This is another opportunity to teach AI search engines what the current truth is.  

If someone better informed than me can write a piece on the current state of affairs (Mark?), we can place this in the ISNR education documents 

which will inform our Members, our own FAQ section (and our new ISNR GPT)  and AI at large.  

Best,
John Mekrut

[Brandi Johnston]

Good to hear!

Sent from my iPhone

On May 23, 2026, at 12:49 PM, 'Robert Thatcher' via ISNR_Members_Forum <isnr_memb...@googlegroups.com> wrote:



To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/1258000307.3234866.1779562123330%40mail.yahoo.com.

[Rob Longo]

John:

 

You wrote:  “This is another opportunity to teach AI search engines what the current truth is.  If someone better informed than me can write a piece on the current state of affairs (Mark?), we can place this in the ISNR education documents which will inform our Members, our own FAQ section (and our new ISNR GPT)  and AI at large.”

 

I so appreciate your enthusiasm and ideas.  What I am hoping you and others here following this thread will understand is the following:

 

Teaching an AI search engine to search for the truth on any topic related to QEEG, NFB, photo-biomodulation, neuroregulation, etc. etc., is not that simple.  I have a close friend who is a major AI player and developer and has worked with google. (and keep in mind that students can now major and get degrees in AI use and development). And I mentioned in a previous post on the listserv… Most people barely know how to do a basic search using Google and other search engines. Using Chat GTP, CoPilot, etc., is no different. A simple inquiry can generate misinformation (PLEASE SEE THE ARTICLE LISTED AT THE BOTTOM OF THIS POST)

 

He listed for me the following brief bullet statements regarding AI and how it works (this is a simplified version):

 

1. Most people use social media and AI is full of misinformation from Social Media. AI is listening to everything we do on line. Thus, if we are pulling in bad info, AI is learning that on our behalf.
2. One must develop tools and generate rules and code for AI to follow. This requires time and a thoughtful process.
3. The tools (when properly created) help build a unified code that AI uses to generate correct information and rule out bad info.
4. This is a process that takes time.
5. Once you generate AI information one needs to reverse the process to see if everything submitted was used and transposed accurately. So, it must be reverse checked much like translating a document from English to another language like Spanish.  The Spanish version needs to be translated back into English to make sure it is accurate.  The same needs to be done with AI.  Are any references generated quality references from peer reviewed journals, or just info on line and from news casts?
6. A single AI article on the ISNR Web Cite is not going to be helpful at all.
7. ISNR would need to have a qualified professional generate a customized AI tool for ISNR members to use.

 

In summery: A good AI tool would certainly help increase the growth of ISNR, but that AI tool needs to be developed for ISNR by someone skilled in AI development.

 

Of course this is a different item than ISNR generating “our own FAQ section”. And, to create “our new ISNR GPT) and AI at large” will entail what I have mentioned above.

 

I hope this helps.

 

AI-generated fake citations are flooding scientific literature across publications, scientists warn

https://phys.org/news/2026-05-ai-generated-fake-citations-scientific.html?utm_source=nwletter&utm_medium=email&utm_campaign=weekly-nwletter

Rob Longo

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/8167e7f4-b943-4b62-b334-aabe0bc4ff7bn%40googlegroups.com.

[Siegfried Othmer]

David Cantor writes:

“The same argument can be made for EMDR. While the body of evidence is relatively limited, because it is coded under psychotherapy, it is generally approved. In many cases, insurance companies lump together any procedure using "sensors" as not being psychotherapy, making the codes arguable.”

It helps that there is an identification of EMDR with a particular discipline, which is not the case for NF. My thoughts go in multiple directions. Firstly, EMDR is based on a physiological mechanism. That means the boundary between the realm of the mind and that of physiology remains breached within the field of psychology. That de facto boundary was effectively established when psychology walked away from Biofeedback, which it totally owned at one time, and also distanced itself from NF. Since instrumental Biofeedback had already eclipsed Autogenics and Progressive Relaxation, it also forgot about those. 

Given what we now know about the centrality of early trauma among the most challenging of cases in mental health, combined with our understanding that the trauma response system is largely physiologically rooted, the field of psychology is curiously distancing itself from its frontier as well as from its history.

This brings us back to EMDR. It stumbles just when it encounters those more intractable cases of early trauma, steeping the client further into disregulation. It falters just where it is most needed. Health professions do not consider the costs they impose on those with whom they fail. They are left worse off than before, both psychologically and physically. 

As Bessel van der Kolk frames it, “Any therapy that does not place regulation front and center is likely to miss the mark.”  In our emerging reality, NF is the indispensable remedy for deep trauma. And in my parochial perspective, the remedy lies in combining Endogenous Neuromodulation in the Infra-Low Frequency regime for restoration of self-regulatory integrity with traditional Alpha-Theta training for psychological resolution and the encounter with the core self. Deep trauma does not have to be remembered in order for the trauma response system to be deconstructed. It rests on physiological memory. In both domains, ILF and A/T, the process is inner-directed. In our attempt to alter our nature, we must act in accord with our nature. 

Regulation of health practices does not lead; it follows. The reality on the ground has to change first, just as it did in the case of EMDR. Self-interest in augmentation of their skill set should suffice to induce psychologists to incorporate self-regulation technologies into their practices, independently of the issue of reimbursement. 

Siegfried Othmer, Ph.D.

Chief Scientist, The EEG Institute

Los Angeles

www.eeginfo.com

www.eeginstitute.com

[sarahprinsloophd]

Morning everyone !  Dave, I'd love to lobby for a neurofeedback day/week/month!  How did you start that process if you don't mind sharing? 

David S. Cantor, Ph.D., M.S., FNAN, QEEG-D, BCNFounder & Clinical DirectorMind and Motion, LLCP: 678-749-7600 x101F: 678-749-7611A: 5050 Research Ct. #800, Suwanee, GA 30024W: www.mindmotioncenters.comE: can...@mindmotioncenters.com

[Sarah Prinsloo, PhD]

Mark, beautifully said. My view is that if we want neuromodulation to be taken seriously within medicine, we have to speak the language of medicine. As my mentor Dr. Lyle used to remind me, the moment communication stops, the possibility for change disappears.

I worry when practitioners position neuromodulation as somehow “outside” or “in competition with” medical frameworks. That mindset only isolates us. In my experience, physicians are not hostile to what we do as most are genuinely curious, open to innovation, and eager for tools that help their patients. They simply don’t know we exist, or they haven’t seen our data presented in a format that aligns with their training and expectations.

If we want to be part of the medical conversation, we have to show up like medical professionals: organize our existing data, write a white paper, stop siloing ourselves, present at medical conferences and consistently include the current science, including our own clinic‑level PRE/POST outcomes. The latter is also helpful when hoping to collaborate.

Anecdotes like “my client got so much better” may be meaningful in the therapy room, but they are not enough to move a healthcare system. Objective and subjective measurements are the bridge. My bias is that every practitioner should be doing at least one assessment before neuromodulation and one after. Without that, we lose the opportunity to demonstrate impact, contribute to the evidence base, and advance the field.

If we want legitimacy, collaboration, and referrals, we have to meet medicine where it is with clear communication, solid data and a willingness to collaborate. We are not dealing with the enemy here, this is a HUGE opportunity and someone will take it if we don't.

Warmly,

Sarah

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/CALktnyAZpUncEbjcnjuGXwmfGBbJxUrdxeon%3D-0LCQsOUzp-bQ%40mail.gmail.com.

[Merlyn Hurd PhD]

Hi Everyone,

I have been following this discussion closely and agree that we must continue working toward the recognition of neurofeedback as a mainstream mental health treatment. However, I have noticed a lack of mention regarding the inclusion of qEEG in the recent CPT work or in the studies recommended for future research.

In addition to the lack of attention to qEEG, I am curious about the status of various stimulation techniques—such as tDCS, tACS, PEMF, and tRNS—within the neurofeedback framework. Are these being folded into the neurofeedback CPT code? These stimulation methods are significantly weaker than rTMS and are already being registered with the FDA for indications like depression and insomnia.

As we know, rTMS is FDA-approved for depression and involves strong magnetic electrical stimulation. Because of its intensity, it is typically limited to a few minutes per session and is primarily administered by psychiatrists. Given that these other neuromodulation techniques are much milder, I would appreciate any insight into how they are being categorized and billed in relation to our current codes.

Best regards,

Merlyn  Hurd PhD QEEG-DL

~~

Having b

MERLYN HURD PHD, PSYCHOLOGIST, P.C.,QEEG DL BCB BCN  Senior Fellow

New York State Licensed Psychologist 7301

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Former Chairperson of the International QEEG Certification Board

Former editor of International Society of Neurofeedback & Research's Newsletter NeuroConnections

Chapter author in Handbook of Clinical EEG and Neurotherapy

Chapter author in Neurofeedback the First Fifty Years

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To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/CAA6yvVYsHrb5nB6yZmQdA2V1uzdrrUY2KL93%3Dsv9Npgr8ifu2w%40mail.gmail.com.

[Nathália Oliveira]

Dear members,

Thank you all for this incredibly insightful and essential discussion. As part of the board, I fully agree that we cannot simply accept blanket denials or let outdated classifications define our field.

Rob and John raised a critical point regarding how the general public and AI engines process this information. To address this practically, I would like to propose a concrete initiative: we can develop and provide an API framework connected to Gemini and ChatGPT, feeding it directly with a robust database of high-impact scientific articles, randomized controlled trials (RCTs), and official ISNR guidelines.

To kickstart this content curation, I am completely at your disposal to write and structure a paper/position paper focused on the most recent advances and scientific achievements in neurofeedback, which can serve as a foundational blueprint to train these models.

By executing this fine-tuning through an API or dedicated assistants, we ensure that any query made by professionals, patients, or insurance companies regarding our efficacy is answered based on real, current scientific evidence rather than obsolete medical policies. Let’s channel this momentum into clear, operationalized tools for our community.

Warm regards,

Nathália Oliveira

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/CAAGjQZyRV7HExVvDKce_ZWQwqPpp8Lg%2B0ydG__f0sbCBvLD-qQ%40mail.gmail.com.

[Rachael Cavegn]

Sarah, thank you for this perspective and I couldn't agree more. I have found that collaborating with the medical team at my clinic has given neurofeedback  significantly increased credibility because these providers are seeing positive results and so are continually sending me more of their patients. They already have credibility (both scientifically and/or socially constructed) and are now extending that credibility to the work I am doing with neurofeedback. They  make sure to document in patient charts the positive influence they are observing as a result of the training. In turn I also participate in their clinical consultation groups and am learning about all kinds of medical variables that influence functioning and inform my training selections. 

I think when we find healthcare providers who are genuinely focussed on client well-being then collaboration and thus credibility becomes fairly easy to achieve because as we all know- neurofeedback works, and providers of all disciplines who have their clients best interest in mind are very happy about this. But it's just one piece of the puzzle. I myself am very happy when a client finds a new medication regimen that allows them to participate in neurofeedback training more thoroughly or a primary psychotherapist who can devote further time to helping clients integrate the advantages of new neuronal connections.  

Interestingly, I have recently been surveying several of my clients who have extensive histories in seeking relief from mental health struggles (10, 20, 30+ years of trying "everything") about their thoughts on their experience of our healthcare system. Three themes keep emerging in their answers- 1) they believe the system has often made their health worse- they have been taught they are extremely ill and will likely remain as such 2) whenever they have experienced periods of improved health each type of provider essentially takes exclusive credit for it, yet they continually return to their struggle 3) they believe their health could have vastly improved if providers would have consulted with each other more instead of working in our silos. 

Now that I have been with my clinic a couple of years I am hoping to start organizing some of the data about client outcomes before and after collaboration.

Rachael Cavegn, LMFT, BCN

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/CAFLTKoM6JUnnWQLp65LUA-F_MTWihrSf1sE_qs4bvjZFw1_dhQ%40mail.gmail.com.

[Saul Rosenthal]

Greetings all,

Like many of you, I’ve been following this thread (and similar discussions throughout the years. I think the comments reflect many of our strengths and weaknesses.

The following is my opinion only, and I am more than open to persuasion.

First, a quick few points why I think I speak with some understanding of the issues:

• I’ve been working with Mark on the CPT problem for 10 years, give or take
• I’m an editor and contributor to the latest edition of Evidence-based practice in biofeedback and neurofeedback
• I’ve been a board member of NRBS and AAPB (where I now serve as president) for many years
• In addition to my clinical practice, I’ve taught, mentored, and run biofeedback services for more years than I’d care to say

Here are some of my general opinions. 

First, I think there are a few (at least) primary challenges we face:

1. We are a tiny, tiny, tiny minority of health care practitioners.

2. We are not just health care practitioners — we are engineers, performance coaches, businesspeople, etc., etc., etc. Even within health care, we are a diverse bunch. For example, as a licensed psychologist, I am not able to use any stimulation intervention — it’s considered outside my scope of practice (at least in Massachusetts). I think this diversity probably diffuses our efforts.

3. This is a point about which I think many will disagree — we do not have a very strong evidence base. Our literature is full of small, uncontrolled semi-studies without much in the way of standardized procedures.

4. We are fractured and siloed, which diffuses our small field even more.

Points like these often lead to discussions with variations of “NFB works, it’s just the demand for randomized controlled trials that’s the problem!” I agree, but I think we need to move past that. If we want to be accepted into mainstream medicine, we have to play by the mainstream medicine rules (which, yes, I agree aren’t even very good for mainstream medicine).

That all said, there is certainly enough published evidence that we have successfully gotten through some new codes. That said, in my opinion those codes in large part went through due to the stronger evidence-base in biofeedback, and because other professional organizations joined with us (psychologists, nurses, and physical therapists).

I do think there are some movements that are very much in our favor. 

First, I think there are more attempts to develop and carry out RCTs for neurofeedback and other types of neuromodulation. While there is still enormous variation in the definition of “neuromodulation,” I’m hopeful that a few threads will emerge, allowing us at least an expansion of CPT codes and more acceptance (a rising tide and all that).

Second, there are a a growing number of voices within our field that are calling for more unification (not the same as saying we should all do the same thing) — in particular, Siegfried Othmer, Tiff Thompson, and Jessica Eure and Christine Tyrrell Baker via NRBS. I think we should have more of this.

Finally, over the history of my practice, I and my colleagues have been getting more referrals from mainstream medical providers. A decade or so ago, I had neurologists telling me neurofeedback can’t do anything because everybody’s brain is different (think on that for a minute or two). Now I’m regularly getting referrals from neurology and giving grand rounds. Related, more actual people are interested in interventions beyond the “mainstream."

All in all, we have real challenges that, fairly or not, we have to accept. I think our strengths lie in our community and in the fact that what we do works. I think we need to focus hard on those and build up arguments that are acceptable to the mainstream. Perhaps picking something as a first focus. For example, maybe we decide on PTSD, agree on some sort of common research framework and develop appropriate evidence.

Finally (part 2), to echo one of Mark’s points — this is a long-term effort. I hope we can build on some of the initiatives that are emerging in a cooperative, coordinated, and systematic fashion.

Thanks to everybody who has contributed to this thread. It’s generating a lot of great thoughts and hopefully some more movement.

Best,

Saul

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/CALktnyAZpUncEbjcnjuGXwmfGBbJxUrdxeon%3D-0LCQsOUzp-bQ%40mail.gmail.com.

---------------------------------------
Saul Rosenthal, PhD
Licensed Psychologist
Fellow, Association for Applied Psychophysiology and Biofeedback
Board Certified in Biofeedback, HRV Biofeedback, Neurofeedback, and Quantitative EEG

advancedbehavioral.care

Enjoy the podcast Healthy Brain Happy Body



617 340-2180

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[sarahprinsloophd]

You all inspired me to dive into my latest analysis (even though I’m currently in the middle of a full‑blown software crisis thanks to Microsoft). I ran a small pilot with patients who had just been diagnosed and were about to start chemo. The question was simple (and it is a very small dataset): could they “hold” the amplitude in the three biomarker regions we’ve published over the years—and if they could, would that protect them from developing neuropathy?

The prelim results are pretty exciting. Everyone showed some degree of targeted response to NFB, but the people who had the biggest amplitude increases in those regions did not go on to develop neuropathy. There’s a lot more to unpack in this dataset, but I couldn’t wait to share the early signal.

So exciting.

[Mark Trullinger]

Hello Everyone,

I wanted to provide some clarity regarding FDA clearances and permissible marketing claims for neurofeedback devices.

Dr. Thatcher is correct that NeuroGuide has FDA clearance. However, that clearance does not allow the specific clinical marketing claims I was referring to. Dr. Thatcher’s message appropriately avoided this pitfall by stating the device has clearance and noting who uses it, rather than discussing what it can be used for or what can legally be claimed. For example, manufacturers cannot say that a device is an "adjunctive treatment for PTSD in adults" without specific clearance for that indication.  Even to use the CPT codes, it requires at least an FDA under certain specific categories.  Not FDA, no use of CPT codes, no insurance reimbursment.

To help everyone understand how the FDA categorizes medical device claims, here is a summary of the three distinct levels (I made up the levels, they are not common language used to identify those levels):

• 1st Level: General Authorization: This covers "clearance" or "granted" status for Class II medical devices with no specific condition indications. Almost all neurofeedback technology today, including NeuroGuide, falls into this category. This level operates entirely "off-label". Because it is often viewed as a last-resort option, it makes securing insurance coverage and doctor referrals difficult.
• 2nd Level: Authorization with Specific Adjunctive Indications: This allows a device to explicitly claim it is an adjunctive treatment for a specific condition (e.g., PTSD in adults). Currently, Gray Matters' PRISM system is the only neurofeedback device cleared to make this claim. As Dr. Rosenthal mentioned, biofeedback for certain conditions have more evidence including here as some devices have this indication and more indications for other conditions. Level 2 clearance helps open insurance pathways—much like Transcranial Magnetic Stimulation (TMS) initially did with "fail-first" requirements—by signaling to insurance companies that the device can be trusted if Level 3 interventions fail or are refused.
• 3rd Level: Primary Treatment Indication: This indicates a device stands alone as a first-line treatment for specific conditions. Reaching this level requires a higher standard of research that is not yet fully defined, though viable pathways using existing study designs and control groups exist. No neurofeedback device currently holds Level 3 status, but it should be covered by all insurances as a primary treatment. Furthermore, achieving Level 3 would allow us to launch massive public awareness campaigns.

The regulatory research bar to move from Level 1 to Level 2 is actually not that high. It typically requires a study of about 80 participants with a follow-up period and significant progress on an accepted symptom measure—no control group required. In fact, some biofeedback manufacturers secured Level 2 clearance without conducting new trials simply by submitting existing research performed with other devices that did not even currently have FDA clearance.

Achieving these advanced clearances makes clinical advocacy and public awareness vastly more effective because we can make specific, targeted statements about specific conditions. Dr. Cantor’s current achievements in Georgia given our field's current research and FDA statuses are phenomenal. However, his success proves the point: imagine how much more could happen, and how much easier it would be, if we had stronger FDA backing to stand on? Why hold ourselves back or set a lower bar of expectation for our field?

Regarding subthreshold stimulation options, these belong to separate FDA categories and require their own independent or combined clearances. They cannot simply be grouped under standard biofeedback or neurofeedback categories. They will also need their own CPT codes for stand-alone or possibly even combined with biofeedback/neurofeedback.

Regarding QEEG brain mapping, our field put forward a strong effort to secure specific insurance codes, but it was not feasible at the time. However, some CPT Category III codes are emerging for algorithmic QEEG analysis that leads to specific TMS protocols. A few versions of these codes have been submitted and accepted. Category III codes require proof of evidence, and the manufacturers in those cases had active, ongoing FDA clinical trials. This brings us right back to the vital link between research and FDA clearance.

Up until now, our field's strategy has been focused entirely on survival. I believe it is time to shift our mindset from surviving to thriving, gaining back autonomy and control over our own future. This can only happen if we actively focus on and invest in these regulatory goals and work toward integrating with the medical field.

I am a NeuroGuide customer, and I want to see the platform pursue these specific indication clearances for neurofeedback and QEEG. I also use Brainmaster and would like to see them do it. I would also like to see other manufacturers pursue this and it could change the equipment I use or convince me to add more. I will support these efforts in any way possible and will gladly give away my knowledge and ideas to see it happen. I have given this knowledge away to multiple device manufacturers, some of whom are already working on these and more. Dr. Thatcher, if NeuroGuide or any other manufacturer is interested, I know these clinical designs, I know how to execute them, and I have access to several universities to conduct the research. I have access to companies who help guide through FDA processes, one of them actually represented one of the QEEG for TMS groups that got a Cat III code and have an ongoing FDA trial. Alternatively, you can take this framework and run with it independently with whomever you choose. I will just give it to you or any genuinely interested device manufacturer.

So again, I ask the community: what do we want, and what actions are we willing to take to make it happen? Dr. Thatcher, would you and NeuroGuide like to talk about specific indications for neurofeedback and QEEG? Would any other manufacturer like to step up and talk about action? I am here.

Best,

Mark Trullinger, PhD

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/0490a99b-fe53-4f68-8ecd-c1556992defbn%40googlegroups.com.

[Cortney Amundson]

Cortney Amundson reacted to your message:

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From: isnr_memb...@googlegroups.com <isnr_memb...@googlegroups.com> on behalf of Nathália Oliveira <nathaliaol...@gmail.com>
Sent: Monday, 25 May 2026 15:34:41
To: isnr_memb...@googlegroups.com <isnr_memb...@googlegroups.com>

Subject: Re: Recap of Today's ISNR Discussion Group - Insurance Companies Still Consider NFB Experimental

 

Dear members,

To view this discussion visit https://groups.google.com/d/msgid/isnr_members_forum/CAArs_WTsGxOaXquKAEoxph9sAO1buiW_%3D_92abZ--QRCmxtF1g%40mail.gmail.com.