Medical Policies Available Online

NOTE** Review policies online to determine if the policy applies to both BCBSND Commercial and/or Medicaid Expansion Plans.

Blue Cross Blue Shield of North Dakota (BCBSND) regularly 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 May 24, 2022. To review our medical policy changes, visit our BCBSND website under medical policies. Listed are the policy updates for July 2022.

The following medical policies were revised:

• Pulmonary Rehabilitation
  • Quantity Level Limits changing to 36 visits and a lifetime max of 72.
• Pain Management of Peripheral Nerves by Injection
  • Adding Trigger Point Injections to policy
  • Adding Occipital Nerve Blocks to policy
• Cosmetic and Reconstructive Surgery
  • Added vulvectomy and labiaplasty
  • Revising the scar revision section
  • Must be 18 years of age to qualify for a reduction mammoplasty/breast reduction
• Proton Beam Radiation Therapy - FM HomeBuilders Consortium and Eide Bailly only
  • Title Change, was Proton Beam Radiation Therapy - FM HomeBuilders Consortium only
• Assisted Reproductive Technology
  • Removed criteria for ICSI
• Durable Medical Equipment
  • Adding RomTech Portable Connect Rehab Adaptive Device to noncovered table
• Discography
  • Detailing Cervical and thoracic discography
• Surgical Treatment of Varicose Veins
  • Adding medical necessity criteria
• Manipulation Under Anesthesia
  • Adding not medically necessary statement
• Electroencephalogram
  • Changing the way not medically necessary statement is written
• Esophageal pH Monitoring
  • Multichannel intraluminal impedance-pH monitoring is now medically necessary with criteria
• Autonomic Nervous System Function Testing
  • Changed statement from E/I to not medically necessary
• Nerve Ablation and Injection
  • Expanded E/I statements to Nerves instead of isolated to the "knee"
  • Title Change was Radiofrequency Ablation of Peripheral Nerves to Treat Chronic Knee Pain
• Posterior Tibial Nerve Stimulation
  • Adding: Implantable Tibial Nerve Stimulation 
  • Implantable tibial nerve stimulation is considered not medically necessary.
• Miscellaneous Services
  • Adding not medically necessary statement
• Corneal Topography/Computer-Assisted Corneal Topography/ Photokeratoscopy
  • Added summary of evidence paragraph
• Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
  • Added summary of evidence and added references.
• Tumor Markers (CA-125)
  • Changed verbiage from CPT to procedure code

The following medical policies are consent policies:

• Feeding Disorder Program
• Leadless Cardiac Pacemaker
• Ocular Photodynamic Therapy (PDT)
• Pap Smears with Medical Conditions
• Ilizarov Bone Lengthening
• Hospice
• Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
• Cervical Fusions
• Acellular Dermal Matrix Grafts
• Nebulizers
• Urological Supplies
• Home Health - Extended Hours
• Cerebral Oxygenation Monitoring using Near Infrared Spectroscopy (NIRS)
• Ultrafiltration in Decompensated Heart Failure
• Biomarkers in Risk Assessment and Management of Cardiovascular Disease
• Non-Powered Negative Pressure Wound Therapy System
• Negative Pressure Wound Therapy (NPWT) Pumps/Vacuum Assisted Closure (VAC) of Chronic
• Cardiac Ablation Procedures

The following medical policies had coding chances:

• Cosmetic and Reconstructive Surgery
  • Added vulvectomy and labiaplasty, codes:  56620, 56625, and 15839
• Home Pulse Oximetry Device
  • Add diagnosis code Q20.2 to both E0445 and A4606.
• Vitamin D Assay
  • For 82652
    • Remove N18.3
    • Add N18.30; N18.31 & N18.32
• Orthopedic Applications of Platelet-Rich Plasma
  • Remove code 86999
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
  • Adding procedure codes to policy
• Manipulation Under Anesthesia
  • Removing 1 Dx code
• Electroencephalogram
  • Procedure and dx coding logic updates
• Autonomic Nervous System Function Testing
  • Added Dx codes
• Nerve Ablation and Injection
  • Added additional codes from as E/I
• Tumor Markers (CA-125)
  • Adding and removing Dx codes
• Photodynamic Therapy (PDT) with Porfimer Sodium
  • Update of diagnosis codes
• Experimental-Investigational
  • Removing:
    • 64454
    • 64625
    • 0440T, 0441T, and 0442T
    • J9021
• Pain Management of Peripheral Nerves by Injection
  • Removing code G9770
  • Adding 20552, 20553, 64405
• Discography
  • Remove 64999
• Esophageal pH Monitoring
  • Procedure and dx coding logic updates
• Miscellaneous Services
  • Adding 93998
• Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
  • Updating Dx codes