Procedures listed in the fee schedules are for use by medical doctors, osteopathic physicians, licensed psychologists and other qualified providers as determined by department policy. All providers of biofeedback are bound by the medical aid rules and fee schedule for biofeedback services.

Administration of biofeedback treatment is limited to those practitioners who are certified by the Biofeedback Certification Institute of America or who meet the minimum education, experience, and training qualifications to be so certified. Those practitioners wishing to administer biofeedback treatment to workers, must submit a copy of their biofeedback certification or supply evidence of their qualifications to the department or self-insurer.

(1) The department will authorize biofeedback treatment for the following conditions when accepted under the industrial insurance claim:

(a) Idiopathic Raynaud's disease;

(b) Temporomandibular joint dysfunction;

(c) Myofascial pain dysfunction syndrome (MPD);

(d) Tension headaches;

(e) Migraine headaches;

(f) Tinnitus;

(g) Torticollis;

(h) Neuromuscular reeducation as result of neurological damage in CVA or spinal cord injury;

(i) Inflammatory and/or musculoskeletal disorders causally related to the accepted condition.

(2) Twelve biofeedback treatments in a ninety-day period will be authorized for the above conditions when the following is presented:

(a) An evaluation report documenting:

(i) The basis for the claimant's condition;

(ii) The condition's relationship to the industrial injury;

(iii) An evaluation of the claimant's current functional measurable modalities (i.e., range of motion, up time, walking tolerance, medication intake, etc.);

(iv) An outline of the proposed treatment program;

(v) An outline of the expected restoration goals.

(b) No further biofeedback treatments will be authorized or paid for without substantiation of evidence of improvement in measurable, functional modalities (i.e., range of motion, up time, walking tolerance, medication intake, etc.). Only one additional treatment block of twelve treatments per ninety days will be authorized. Requests for biofeedback treatment beyond twenty-four treatments or one hundred eighty days will be granted only after file review by and on the advice of the department's medical consultant.

(c) In addition to treatment, pretreatment and periodic evaluation will be authorized. Follow-up evaluation can be authorized at one, three, six, and twelve months posttreatment.

(d) At the department's option, a concurring opinion may be required regarding relationship of the condition to the industrial injury and/or need for biofeedback treatment.

The codes, reimbursement levels, and other policies for biofeedback services are listed in the fee schedules.