Applies to both Commercial and Medicaid Expansion
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 Jan. 14, 2025. To review our medical policy changes, visit our BCBSND website under medical policies.
The following medical policies were revised:
- Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
- In the 'In-lab Sleep Study' section of policy, a new bullet was added: The member has or is suspected to have one or more of the following (potentially injurious parasomnias, narcolepsy, suspected narcolepsy, or suspected idiopathic hypersomnia)
- Telehealth
- Added January 2025 new telehealth codes, and policy verbiage
- Allergy Skin Testing
- Skin Endpoint Titration (SET) section procedure codes removed “and medically necessary” and added “experimental/investigational”
- Miscellaneous Services
- Added bullet to the Not Medically Necessary section of policy: Continuous Passive Motion (CPM) remote stationary cycling device (i.e., ROM3® Rehab, ROMTech AccuAngle®, ROMTech PortableConnect®)
- Cosmetic Surgery vs Reconstructive Surgery
- Added “Lagophtholmos” to the Canthopexy section of the policy
- Under hair removal (permanent): removed targeted hair removal is appropriate
- Verbiage update to Otoplasty section (section was created into two bullet points)
- Allergy Immunotherapy
- New section to establish criteria for rapid desensitization with procedure code 95180
- Added bullets to Allergy Immunotherapy section regarding documentation criteria
- Vertebral Body Tethering
- Updated criteria verbiage: adding an “add” between bullet points
- Posterior Tibial Nerve Stimulation
- Changed criteria bullet from “needing one anticholinergics” to “only one needed”
- Implantable Cardioverter Defibrillators
- Policy statements and policy guidelines statements for pediatric indications updated
The following medical policies are consent policies:
- Diabetic Services and Supplies
- Breast MRI
- Physical Therapy
- Sports Physical
- Occupational Therapy
- Manipulation Services
- Proton Beam Therapy
- Assisted Reproductive Technology
- Ambulance Services: Ground Transportation
- Myoelectric Prosthetic Components for the Upper Limb
- Tumor Treatment Fields
- Pneumatic Compression Devices
- Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents
- Apos Therapy System
- Nerivio
- Intracellular Micronutrient Testing Panel
- WATS3D Biopsy (EndoCDx)
- External Counterpulsation
- Ambulatory & Outpatient Cardiac Hemodynamic Monitoring of Heart Failure
- Mobile Cardiac Outpatient Telemetry MCOT
- Foot Orthotics for Conditions Other Than Diabetes
- In Vitro Allergy Testing
- Intraepidermal Nerve Fiber Density Testing
- Rapid Platelet Function Assay
- Corneal Transplantation
- Small Bowel, Small Bowel/Liver and Multivisceral Transplant
- Lung and Lobar Lung Transplantation
- Heart-Lung Transplantation
- Pancreas Transplant
- Ablation of Liver Tumors
- Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions and Soft Tissue Wounds
- Ovarian and Internal Iliac Vein Embolization for Pelvic Congestion Syndrome
- Bulking agents for the Treatment of Urinary Stress Incontinence and Vesicoureteral Reflux
- Breast Ductal Lavage and Fiberoptic Ductoscopy
- Echosclerotherapy
- Sclerotherapy (Liquid or Microfoam)
- Subfascial Endoscopic Perforator Surgery (SEPS)
- Endovenous Cryoablation
- Laser Treatment, Non-Invasive
- Spider Veins, Treatment
- Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
- Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
- Cochlear Implantation
- Transcatheter Mitral Valve Repair/Replacement
- Cardiac Contractility Modulation Therapy
- Laser Interstitial Thermal Therapy
- Intraperitoneal Chemotherapy
- Vitamin D Assay
- Cardiac Rehabilitation Programs, Phase II Outpatient
- Experimental/Investigational
- Treatment of Benign or Premalignant Skin Conditions
The following medical policies had coding changes:
- Bioengineered Skin and Soft Tissue Substitutes
- Added January new codes: 15011, 15012, 15013, 15014, 15015, 15016, 15017, and 15018
- Electromagnetic Navigational Bronchoscopy (ENB)
- Added January new code: C1739
- Intra-Arterial/Intravenous Therapeutic Procedures
- Added January new code: C7563
- Ablation of Miscellaneous Solid Tumors
- Added January new codes: 60660 and 60661
- Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)
- Added January new codes: 61715 and 0947T
- Removed deleted codes: 0398T and C9736
- Amniotic Membrane and Amniotic Fluid
- Added January new codes: Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, and Q4353
- Prostate Disease: Diagnosis, Staging, and Treatment
- Added January new codes: 51721, 53865, 53866, 55881 and 55882
- Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
- Added January new code: D9959
- Telehealth
- Added January new codes: 98000, 98001, 98002, 98003, 98004, 98005, 98006 and 98007
- Added new dental codes
- Dynamic Splinting Devices
- Added January new code: E1803, E1804, E1807, E1808, E1813, E1814, E1822, E1823, E1826, E1826, E1827, E1828 and E1829
- Radiofrequency
- Annual Review for ND
- Added diagnosis codes: M47.24, M47.25, M47.814, M47.815, M47.894, M47.895, M50.11, M50.121, M50.122, M50.123, M51.14, M51.15, M51.16, M51.17, M54.51, and M54.6
- Experimental/Investigational
- Added January New Codes (effective January 1, 2025):
- 66683, 82884, 92137, 93896, 93897, 93898
- 0524U, 0525U
- 0901T, 0902T, 0903T, 0904T, 0905T, 0906T, 0907T, 0908T, 0909T
- 0910T, 0911T, 0912T, 0913T, 0914T, 0915T, 0916T, 0917T, 0918T, 0919T
- 0920T, 0921T, 0922T, 0923T, 0924T, 0925T, 0926T, 0927T, 0928T, 0929T
- 0930T, 0931T, 0932T, 0933T, 0934T, 0935T, 0936T, 0937T, 0938T, 0939T
- 0940T, 0941T, 0942T, 0943T, 0944T, 0946T o C1735, C1736, C8002, C8003, and C9807
- Removed deleted codes: 0553T, 0567T, 0616T, 0617T and 0618T
- Removed procedure codes: 0899T, 0890T, 0891T, and 0892T
- Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
- Added diagnosis code M54.6
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Added January new code C1737
- Miscellaneous Services
- Added procedure code E1399
- Drug Testing
- Changed diagnosis code F10.1230 to F10.120
- Removed F10.830 and 0.950 as they are invalid codes
- Removed duplicate procedure codes
- Radioembolization for Primary and Metastatic Tumors of the Liver
- Added diagnosis code C22.1
Questions?
Contact the appropriate Customer Service Provider Center: Commercial: 1-800-368-2312 or Medicaid Expansion: 1-833-777-5779.
