NOTE** Review polices online to determine if the policy applies to both BCBSND Commercial and 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 July 21, 2022 and will be effective September 2022, unless noted. The polices listed below will be updated within the next 30 days. To review our medical policy changes, visit our BCBSND website under medical policies.
The following medical policies are new:
The following medical policies were revised:
- Cardiac Ablation Procedures
- Changing E/I statement to not medically necessary
- Rapid Platelet Function Assay - ASA
- Was: investigational/experimental
- Will be: experimental/investigational
- Intraepidermal Nerve Fiber Density Testing
- ADDING: Measurement of sweat gland nerve fiber density is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
- Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy
- Changing E/I statement to not medically necessary
- Deep Brain Stimulation
- Changing E/I statement to not medically necessary
- Adding criteria: The individual has an average of six (6) or more seizures per month, over the three (3) most recent months prior to DBS implantation (with no more than 30 days in between seizures)
- Electrical Nerve Stimulation
- Adding:
- External Trigeminal Nerve Stimulation System.
- External Upper Limb Tremor Stimulator
- Transcutaneous Electrical Modulation Pain Reprocessing Therapy.
- Physical Therapy
- Removal Of Some E/I That Are Now Standard Of Care
- Wearable Cardioverter-Defibrillator
- Added additional options for medically necessary criteria
- Percutaneous Left Atrial Appendage Closure Devices
- Very limited verbiage change: updated to state, FDA approved, etc…
- Cardiac Applications of Positron Emission Tomography Scanning
- Added summary of evidence in the policy
- External Counterpulsation (ECP)
- Revision of not medically necessary statement.
- Change the layout of the policy
- Coronary Revascularization
- Added a not medically necessary statement
- Measurement of Exhaled Nitric Oxide
- Changing E/I statement to not medically necessary
- Gender Affirmation Surgery
- Adding coverage for nipple reconstruction
- Bioengineered Skin and Soft Tissue Substitutes
- Under the E/I section removed all the specific skin and soft tissue substitutes. However, all procedure codes remain for each.
- Occupational Therapy (OT)
- Revision of the way criteria is written, no change to criteria.
- Manipulation Services
- Revision of how criteria is stated
- Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
- Added criteria:
- If no bed partner is available to report snoring or observed apneas, other signs and symptoms suggestive of OSA may be considered as outlined below:
- Male individual greater than 60 years of age; or
- Individual has a thick neck as follows:
- Greater than 17 inches in men; or
- Greater than 16 inches in women; or
- Individual has craniofacial or upper airway anomalies such as abnormal or short maxillary or short mandibular size; or
- Individual has a wide craniofacial base; or
- Individual has tonsillar/adenoid hypertrophy.
- Added criteria: PSG/RLS Criteria:
- PSG may be considered medically necessary for the diagnosis of periodic limb movement disorder
- If no bed partner is available to report snoring or observed apneas, other signs and symptoms suggestive of OSA may be considered as outlined below:
- Added criteria:
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- Adding criteria for PSG: The individual has failed a home sleep test or ANY of the following signs and symptoms
- Also added criteria for: PSG/RLS Criteria: PSG may be considered medically necessary for the diagnosis of periodic limb movement disorder
- Adding Actigraphy may be necessary with PSG.
- Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions and Soft Tissue Wounds
- Revising how a E/I statement is written
- Nebulizers
- Changing the way, the not medically necessary statements are written. No change to coverage / criteria
- Cranial Electrotherapy Stimulation and Auricular Electrostimulation
- Adding word Note in policy in each section
- Adding auricular electrostimulation in operational guidelines
- Electrical Stimulation Devices for the Treatment of Arthritis
- Revision of the E/I statement. No change in coverage, will cont. to be E/I
- Discectomy
- Added summary of evidence in the policy
- Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
- Added summary of evidence in the policy
- Assisted Reproductive Technology
- Criteria from ICSI back into the bottom of the policy as reference
- Hyperbaric Oxygen Therapy
- Revision of how not medically necessary statement is written
- Treatment of Hyperhidrosis
- Adding will expire in three (3) months from the original authorization date for any diagnosis
The following medical policies are consent policies:
- Ultrafiltration in Decompensated Heart Failure
- Aqueous Shunts and Stents for Glaucoma
- WATS3D Biopsy (EndoCDx)
- Transcatheter Mitral Valve Repair/Replacement
- OralCDx Brush Biopsy
- Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
- Diabetic Services and Supplies
- Nucleoplasty and Biacuplasty
- Knee Orthosis
- Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease
- High Resolution Anoscopy (HRA)
- Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover
- Arthrocentesis or Needling of Bursa
- Phototherapy for Psychiatric Disorders
- Automated External Defibrillators for Home Use
- Braces and Supports
- Hematopoietic Cell Transplantation for Solid Tumors of Childhood
The following medical policies had coding changes:
- Cardiac Ablation Procedures
- NEW CODES TO POLICY 93620, C1732, C1733, C2630.
- Updating diagnosis coding logic
- Amniotic Fluid and Amniotic Membrane
- ADDING NEW CODES FOR 7/1/2022:
- 3 new codes Q4259, Q4260 & Q4261
- ADDING NEW CODES FOR 7/1/2022:
- Intraepidermal Nerve Fiber Density Testing
- Adding procedure code 88356
- Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy
- Adding codes 95836, C1767, C1778
- Removing codes 95976 and 95977
- Deep Brain Stimulation
- Adding codes: L8689, L8695, C1767, C1778, C1787, C1818, C1820, C1822, C1883, C1897
- Electrical Nerve Stimulation
- Adding new code for 7/1/2022: 0270T
- Adding additional codes to policy effective 9/5/2022
- Physical Therapy
- REMOVING:
- 97165
- 97166
- 97167
- 97168
- ADDING:
- 4018F
- 90901
- 96125
- 97129
- 97130
- 97545
- 97546
- 97755
- 99339
- 99340
- 99374
- 99375
- 99377
- 99378
- 99380
- G0181
- G0182
- S9124
- S9125
- S9128
- S9129
- S9131
- T1021
- T1025
- T1026
- REMOVING:
- Pain Management by Injection
- Remove 20560 & 20561
- Durable Medical Equipment
- Adding code E0673 to noncovered table: Kinex thermoComp compression appliance is a convenience item
- Pheresis Therapy
- Updating Diagnosis Codes
- Prostate Disease: Diagnosis, Staging, and Treatment
- Add new Code 0714T effective 7/1/2022
- Measurement of Exhaled Nitric Oxide
- Updating / adding 2 covered diagnosis codes
- Oncologic Applications of Positron Emission Tomography Scanning
- Adding A9596 and A9601 new codes
- Drug Testing
- Adding 0328U and updating QLL's
- Occupational Therapy (OT)
- Adding additional procedure codes and adding covered Dx codes
- Manipulation Services
- Removal procedure codes
- Home Dialysis Equipment and Supplies
- Adding code E1629
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- Adding code 95803
- Nebulizers
- Adding 1 diagnosis code
- Ultrasound Osteogenesis Stimulator
- Removal of 1 procedure code
- Corneal Surgery to Correct Refractive Errors, Phototherapeutic Keratectomy, and Corneal Collagen Cross-Linking
- Update diagnosis coding logic for S0812
- Bulking Agents for the Treatment of Urinary Stress Incontinence and Vesicoureteral Reflux
- Update diagnosis coding logic
- Experimental-Investigational
- Removing:
- E1629
- 90587: HMK removed and per Jill it can be removed
- 64454: not in any other ND policies
- 64625: in 1 other ND policy
- 0440T, 0441T, and 0442T: not in any other ND policies
- adding 75571
- Update after new codes came in all effective 7/1/2022:
- 0717T, 0718T, 0719T, 0721T, 0722T, 0723T, 0724T, 0725T, 0726T, 0727T, 0728T, 0729T, 0730T, 0731T, 0732T, 0733T, 0734T, 0736T, 0737T, 0324U, 0325U
- Removing:
The following medical policies will be archiving / retiring as they are part of S-272 effective 9/5/2022:
- Donor Leukocyte Infusion for Hematologic Malignancies that Relapse After Allogeneic Cell Transplant
- Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
- Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
- Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome
- Hematopoietic Cell Transplantation for Amyloid light-chain (AL) Amyloidosis (Primary Systemic Amyloidosis)
- Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia
- Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
- Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
- Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
- Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
- Hematopoietic Cell Transplant for Hodgkin Lymphoma
