3.1 Benefits
are payable for services and supplies in connection with electrothermal, electromyograph
and electrodermal biofeedback therapy when there is documentation
that the patient has undergone an appropriate medical evaluation,
that their present condition is not responding to or no longer responds
to other forms of conventional treatment and only provided in treatment
of the following conditions:
3.1.1 Adjunctive
treatment for Raynaud’s Syndrome.
3.1.2 Adjunctive
treatment for muscle re-education of specific muscle groups or for
treating pathological muscle abnormalities of spasticity, or incapacitating
muscle spasm or weakness.
3.1.3 Payable
benefits include initial intake evaluation. Treatment following
the initial intake evaluation is limited to a maximum of 20 inpatient
and outpatient biofeedback treatments per calendar year.