The Plan will pay for covered health services for medical or behavioral/mental health related education services provided in a physician's office by an appropriately licensed or healthcare professional when:
- Education is required for a disease in which patient self-management is an important component of treatment.
- There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.
Some examples of such medical conditions include, but are not limited to:
- Coronary artery disease
- Congestive heart failure
- Severe obstructive airway disease
- Gout (a form of arthritis)
- Renal failure
- Phenylketonuria (a genetic disorder diagnosed at infancy)
- Hyperlipidemia (excess of fatty substances in the blood)
Note: Benefits for nutritional counseling services are limited to three individual sessions per covered person's lifetime for each medical condition.
When nutritional counseling services are billed as a preventive care service, these services will be paid as described under "Preventive care benefits."