Blue Cross Blue Shield of North Dakota (BCBSND) continually develops and revises medical policies in response to rapidly changing medical technology. Our commitment is to update the provider community as medical policies are adopted and/or revised. Benefit determinations are made based on the medical policy in effect at the time of service.
The following medical policies were reviewed by the Internal Medical Policy Committee on March 11, 2025. To review our medical policy changes, visit our BCBSND website under Medical Policy Search.
The following medical policies are new:
- Pneumatic Compression Devices
The following medical policies were revised:
- Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents
- Removed: ‘as a stand-alone procedure’ from the 'Balloon sinus ostial dilation as a stand-alone procedure is considered medically necessary' statement.
- Cosmetic Surgery vs. Reconstructive Surgery
- Adopted criteria: Individual consideration may be given if the amount of weight to be removed is within 20% of the weight recommended by the Schnur Scale.
- Devices Used for the Treatment of Sleep Apnea in Adults
- Removed statement from policy: "However, if the member is found to be using the PAP device as directed and is achieving the desired results, the DME supplier must contact the individual's physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. Non-compliance with the prescribed PAP therapy will render the PAP device as a non-covered service."
- Photodynamic Therapy (PDT) with Porfimer Sodium
- Professional statements updated
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- Removed bullet Multiple Sleep Latency Testing (MSLT) / Maintenance of Wakefulness Test (MWT) from Home/Unattended Sleep Studies section of policy
- Ultraviolet Light Therapies
- Changed ‘One of the following’ to ‘One or more of the following’
- Changed % to percent
- Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
- Policy broken into sections with procedure codes for each section.
- The first bullet of the "In-lab Sleep Study" section, verbiage changed
- WATS3D Biopsy (EndoCDx®)
- Changed EndoDx to formally known as EndoCDx) and changed ANY to ONE or more
The following medical policies are consent policies:
- Home Dialysis Equipment and Supplies
- Wheelchairs and Options/Accessories
- Lumbar Spinal Fusion
- Intraepidermal Nerve Fiber Density Testing
- Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence
- Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions and Soft Tissue Wounds
- Ambulance Services: Air and Water Transportation
- Dry Needling of Trigger Points for Myofascial Pain
- Percutaneous Electrical Nerve Field Stimulation (PENFS)
- Cleft Palate/Lip Reconstruction
- Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
- Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty
- Manipulation Under Anesthesia
- Electrical Stimulation Devices for the Treatment of Arthritis
- Diagnosis and Treatment of Male Sexual Dysfunction
- Implantable Pulmonary Artery Pressure Measurement Device
- Ostomy Supplies
- Lower Limb Prostheses
- Transcatheter Arterial Chemoembolization
- Ligation, Division, and/or Excision of Varicose Vein Cluster(s)
- Hyperbaric Oxygen Therapy
The following medical policies had coding changes:
- Surgical Treatment of Obstructive Sleep Apnea
- Added procedure codes 61886 and 61888 with diagnosis criteria. (Removed from S-51)
- Added procedure code 64568 with diagnosis criteria
- Surgical Treatment of Femoroacetabular Impingement
- Removed diagnosis codes with description of unspecified side: M24.159, M24.859, M25.559, M25.859, S79.819A, S79.819D, S79.819S, S79.829A, S79.829D, S79.829S, S79.919A, S79.919D, S79.919S, S79.929A, S79.929D, and S79.929S
- Electrical Nerve Stimulation
- Removed procedure codes 61886 and C1820
- Deep Brain Stimulation
- Removed procedure code C1820
- Photodynamic Therapy (PDT) with Porfimer Sodium
- Removed diagnosis code K22.70
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- Removed procedure code 95805 from Home/Unattended Sleep Studies section of policy.
- Added procedure code 95807 to PSG/RLS section of policy.
- Ultraviolet Light Therapies
- Added procedure code A4633 to Home Therapy section of policy.
- Adding diagnosis codes C84.00, C84.01, C84.02, C84.03, C84.04, C84.05, C84.06, C84.07, C84.08, C84.09, L20.0, L20.9, L20.81, L20.82, L20.84, L20.89, L40.0, L40.1, L40.2, L40.3, L40.4, L40.8, L40.9, L41.0, L41.1, L43.0, L43.1, L43.2, L43.3, L43.8, L43.9, L66.10, L66.11, L66.12, and L66.19 to procedure code A4633.
- Removed procedure code E1399 from Home Therapy section of policy
- Added diagnosis code L73.9 to procedure codes 96900, 96912, and 96913.
- Added diagnosis code L30.9 to procedure codes 96920, 96921, and 96922.
- Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
- Removed D9959 (Unspecified sleep apnea procedure).
- Added E0601, E0618, E0619, and E0471 to the Treatment with CPAP and Bi PAP section of policy.
- Cardiac Applications of Positron Emission Tomography Scanning
- Added diagnosis code I25.112
- Artificial Intervertebral Disc Replacement
- Added diagnosis codes M51.27, M51.360, M51.361, M51.362, M51.369, M51.370, M51.371, M51.372, and M51.379 for procedure codes 22857, 22862 and 22865.
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
- Added diagnosis codes: M17.31, M17.32
- Removed diagnosis codes: M17.10, M17.9, M12.569, M23.90, M23.8X9, M25.869, M93.269, S99.819A, S99.819D, S99.819S, S99.829A, S99.829D, S99.829S, S99.919A, S99.919D, S99.919S, S99.929A, S99.929D, and S99.929S
- Liver Transplant
- Removed diagnosis code K83.0
- Added diagnosis codes K83.01 and K83.09
- Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
- Removed diagnosis codes: I24.11, I25.71, I25.72, I25.73, I25.75, I25.76, I25.79, I25.8, I25.81, I82.22, I82.29, I82.4, I82.40, I82.41, I82.42, I82.43, I82.44, I82.45, I8246, I82.49, I82.4Y, I82.4Z, I82.5, I82.52, I82.53, I82.54, I82.55, I82.56, I82.5Y, I82.5Z, I82.6, I82.60, I82.61, I82.62, I82.7, I82.70, I82.71, I82.72, I82.8, I82.81, I82.89, and I82.9.
- WATS3D Biopsy (EndoCDx®)
- Added diagnosis codes: K21.9, K21.00, K21.01, K22.70, K22.710, K22.711, and K22.719
- Feeding Disorder Program
- Added diagnosis codes: F45.9, F50.810, F50.811, F50.812, F50.813, F50.814, F50.819, F50.82, F50.89, and F50.9.
- Removed diagnosis code F50.8.
- Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy
- Removing procedure code 61886
- Experimental/Investigational Services
- Removed procedure codes: 92137, 0568T, 0495U, 22899, and 0691T.
- Added procedure codes: 0332T, 0614T, M0076, and S9025
The following medical policies will be archived / retiring:
- Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
- Pneumatic Compression Devices
