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 Mar. 19, 2024. To review our medical policy changes, visit our BCBSND website under Medical Policy Search.
The following medical policies were reviewed by the Internal Medical Policy Committee on Mar. 19, 2024. To review our medical policy changes, visit our BCBSND website under medical policies.
The following medical policies are new:
- Percutaneous Electrical Nerve Field Stimulation (PENFS)
- Liver Transplant
The following medical policies were revised:
- Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence
- Added the word 'Covered' to Diagnosis Code section. Grammatical changes
- Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty and Biocuplasty
- Added bullet to treatment criteria
- Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
- Added bullets from the AASNM guidelines
- Removed bullets
- Removed section ‘ONM performed for more than one procedure.”
- Temporomandibular Joint (TMJ) Dysfunction
- Changes to criteria verbiage, removed section pertaining to CT, MRI, ROM; changed not medically necessary therefore non-covered to not medically necessary, and added section for Occlusal guards
- Electrical Nerve Stimulation
- Criteria update: operational guidelines revised, removed section Percutaneous Electrical Nerve Field Stimulator, and added Restorative Neurostimulation Therapy section
- Desensitization Treatment for Heart and Renal Transplant
- Last statement in each section re-written changing E/I to not medically necessary
- Implantable Pulmonary Artery Pressure Measurement Device
- Criteria verbiage changes
- Gender Affirmation Treatment
- Title change and additional verbiage rewording
- Physical Therapy
- Criteria verbiage updated
- Biofeedback
- Added section for new code S9002
- Powered Exoskeletal Robotic Systems
- Added section for new code E0739
- Telehome Telemonitoring for Chronic Disease(s)
- Title change and removal of CHF and COPD verbiage and replace with chronic disease
- Gender Affirmation Treatment
- Title change with verbiage rewritten
The following medical policies are consent policies:
- Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
- Surgical Treatment of Femoroacetabular Impingement
- Fetal Surgery for Prenatally Diagnosed Malformations
- Biofeedback
- Dry Needling of Trigger Points for Myofascial Pain
- Allergy Immunotherapy
- Ostomy Supplies
- Ambulance Services: Air and Water Transportation
- Electrical Stimulation Devices
- Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Electronystagmography (ENG) and Videonystagmography (VNG) Services
- Intraocular Lens
The following medical policies had coding changes:
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
- Removed diagnosis codes: S89.90, S89.91 and S89.92
- Added diagnosis codes: S89.90XA, S89.90XD, S89.90XS, S89.91XA, S89.91XD, S89.91XS, S89.92XA, S89.92XD, S89.92XS, S99.819A, S99.819D, S99.819S, S99.821A, S99.821D, S99.821S, S99.822A, S99.822D, S99.822S, S99.829A, S99.829D, and S99.829S
- Lumbar Spinal Fusion
- Removed diagnosis code: M41.51
- Added diagnosis codes: M48.061 and M48.063
- Cleft Palate/Lip Reconstruction
- Added diagnosis codes: Q36.0, Q36.1, and Q36.9
- Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence
- Added diagnosis codes: G43.401, G53.409, G43.411, G43.419, G43.E01, G43.E09, G43.E11, and G43.E19
- Artificial Intervertebral Disc Replacement
- Removed procedure code 0163T
- Added diagnosis codes: M50.13, M50.20, M50.30, M50.80, M50.81, and M50.90, and for procedure codes 22856, 22861, 22864, 22858, 0095T, and 0098T
- Added diagnosis codes: M51.26, M51.86, and M51.87 for procedure codes 22857, 22862, and 22865
- Ambulatory Blood Pressure Monitoring
- Added diagnosis codes: Z00.00, Z00.01, and Z01.31
- Experimental/Investigational
- Removed procedure codes: 67516, 90689, 36836, and 0594T
- April new codes: added procedure codes: A4593, A4594, A9293, G0138, and K1037
- Ablation of Miscellaneous Solid Tumors
- Removed diagnosis codes: C40.00, C40.10, C40.20, C40.30, D16.00, D16.10, D16.20, D16.30, C34.00, C34.10, C34.30, C34.80, C34.90, C78.00, C64.9, C79.00, and D49.519
- Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
- Multiple diagnosis codes removed
- Added the following payable dx codes: G40.A01, G40.A09, G40.A11, G40.A19. G40.B01, G40.B09, G40.B11, G40.B19, G40.C01, G40.C09, G40.C11, G40.C19, G40.001, G40.009, G40.011, G40.019, G40.101, G50.109, G40.201, G40.209, G40.301, G40.309, G40.401, G40.409, G40.501, G40.509, G40.801, G40.802, G40.824, G40.833, G40.834, G40.89, G50.901, G40.909, G40.911, G40.919, G40.A01, G40.A09, G40.A11, G40.A19, G40.B01, G40.B09, G40.B11, G40.B19, G40.C01, G40.C09, G40.C11, G40.C19, G80.3, and Z98.89
- Temporomandibular Joint (TMJ) Dysfunction
- Removed diagnosis codes: M26.609, M26.619, M26.629, and M26.639 (taking out unspecified side).
- Add dx codes: M26.641, M26.642, M26.643, M26.651, M26.652, M26.652, and M26.653.
- Removed procedure codes: 95851 and 95127.
- Added medically necessary procedure codes: 20605, 20606, 21010, 21085, 21089, 21110, 97024, 97110, 97112, 97129, 97130, 97530 and not medically necessary procedure codes 97112, D9944, D9945, and D9946 (Occlusal guards)
- Basivertebral Nerve Ablation
- Added diagnosis code: M54.51
- Electrical Nerve Stimulation
- Removed HCPCS code 0720T and added non-covered diagnosis codes (M62.5A2, M53.86, M53.87, M54.41, M54.42, M54.51, M54.59, and M54.89) for Restorative Neurostimulation Therapy codes (64555, 64575, 64590, 64999, L8679, L8680, L8681, L8683, and L8688).
- Nebulizers
- Added diagnosis codes: J20.0, J20.1, J20.2, J20.3, J20.4, J20.4, J20.5, J20.6, J20.7, J20.9, J21.0, J21.1, J21.8, J21.9, J80, R05.1, R06.02, and R06.2
- Diabetic Services and Supplies
- Added HCPCS code E2100 and diagnosis codes: E13.36, E15, E16.0, E16.3, E16.8, E16.9, E89.1, O24.415, O24.425, and O24.435
- April new codes, added procedure code: E2298
- Removed procedure code: E2300
- Mastectomy and Reconstructive Surgery
- Added procedure codes: 19370 and 19380
- Amniotic Membrane and Amniotic Fluid
- April new codes: added procedure codes: Q4305, Q4306, Q4307, Q4308, Q4309, and Q4310
- Removed procedure codes: Q4244
- Bioengineered Skin and Soft Tissue Substitutes
- April new codes: added procedure code: A2026
- Removed procedure code: Q4172
- Durable Medical Equipment
- April new codes: added procedure code: E0152
- Wheelchairs (WC) and Options/Accessories
- April new codes: added procedure code: E2298
- Removed procedure code: E2300
- Lower Limb Prostheses
- April new codes: added procedure codes: L5783 and L5841
- Physical Therapy
- Addition of procedure code 97116 to Gait Training Section of policy
- Biofeedback
- April new code: added procedure code: S9002
- Powered Exoskeletal Robotic Systems
- April new code, added procedure code: E0739
- Diagnosis and Treatment of Male Sexual Dysfunction
- April new code, added procedure code: S4988
- Gender Affirmation Treatment
- Addition of procedure codes: 15847, 15877, 97110, 97112, 92507, 58180, 58270, 58542, and 58544
The following medical policies will be archived / retiring:
- Oxygen
- CT (Virtual) Colonoscopy
- Ultrafiltration in Decompensated Heart Failure
- Liver Transplant
