Medical Policies Available Online Updates

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 Jan. 16, 2024. To review our medical policy changes, visit our BCBSND website under medical policies. If the policy is currently not updated, it will be within the next thirty days.

Medical Policies

New Policies
Revised Policies
Consent Policies
Coding Changes
Archived / Retired Policies

The following medical policies are new:

  • Nerivio
  • Mobile Cardiac Outpatient Telemetry (MCOT)
  • Echosclerotherapy
  • Sclerotherapy (Liquid or Microfoam)
  • Subfascial Endoscopic Perforator Surgery (SEPS)
  • Endovenous Cryoablation
  • Laser Treatment, Non-Invasive
  • Ligation or Ablation, Incompetent Perforator Veins
  • Spider Veins, Treatment
  • Ligation, Division, and/or Excision of Varicose Vein Cluster(s)

The following medical policies were revised:

  • Cranial Electrotherapy Stimulation and Auricular Electrostimulation
    • References updated
  • Apos Therapy System
    • Medically necessary criteria updated: low back pain
  • Peripheral neuropathy and severe osteoporosis added to not medically necessary
  • Telehome Monitoring for Congestive Heart Failure and/or Chronic Obstructive Pulmonary Disease        
    • Removed 'BCBSND Case Manager' and replaced with 'provider care team.'
  • Treatment of Hyperhidrosis
    • Added: 'Additional authorization may be given if documentation of an objective measurable effect is provided indicating clinical improvement of the condition' to palmer, plantar, and craniofacial sections of policy
  • Ambulatory and Outpatient Cardiac Hemodynamic Monitoring of Heart Failure
    • Reference Updates
  • Heart/Lung Transplant
    • Removed bullet (In both adult and pediatric individuals, isolated cardiac or pulmonary transplantations are preferred to combined heart/ lung transplantation when medical or surgical management-other than organ transplantation-is available) and added bullet/sub-bullets on HIV; updated professional statements and references
  • Pneumatic Compression Devices
    • References updated
  • Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents
    • References update, grammatical changes and the removal of specific sinus implants
  • Intracellular Micronutrient Testing Panel
    • References updated
  • Prostate Disease: Diagnosis, Staging, and Treatment
    • References updated
  • Transcatheter Mitral Valve Repair/Replacement
    • References updated and professional statement updates
  • Myoelectric Prosthetic Components for the Upper Limb
    • Grammatical changes and rewording of criteria
  • Pancreas Transplant
    • HIV criteria added and references updated
  • Ablation of Liver Tumors
    • Criteria, professional statements, and references updated
  • External Counter pulsation
    • Grammatical changes and references updated
  • Lung and Lobular Transplant
    • HIV criteria addition
  • Treatment of Benign or Premalignant Skin Conditions
    • Grammatical corrections and excision bullet
  • Manipulation Services
    • Reference updates and grammatical changes
  • Manipulation Services – Medicaid Expansion only
    • Reference update and grammatical changes
  • Electrical Nerve Stimulation
    • Criteria removed, Remote Electrical Neuromodulation
  • Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease
    • Criteria removed, ANCA/ASCA
  • Surgical Treatment of Varicose Veins
    • Professional guidelines updated, Procedure review criteria removed, Chart containing related individual treatment modality policies/ guidelines added, Definitions for Treatment Session, Vein Anatomy and Common Abbreviations added
  • Basivertebral Nerve Ablation
    • Added criteria bullet for being skeletally mature and update of references
  • Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
    • Changed from always experimental/investigational to medically necessary with covered diagnosis code
  • Radioembolization for Primary and Metastatic Tumors of the Liver
    • Annual review for ND with updates to references
  • Transcatheter Arterial Chemoembolization
    • Updated verbiage, Professional statements, and references
  • Small Bowel/Liver and Multivisceral Transplant
    • HIV specific indications under general criteria
  • Tumor Treatment Fields
    • Annual review update to references
  • Autonomic Nervous System Function Testing
    • Criteria verbiage and professional statement changes, references updated
  • Corneal Transplantation
    • Annual review updates to references
  • Per-Oral Endoscopic Myotomy
    • Annual review updates to references
  • Miscellaneous
    • Denial for procedure code 93702 changed from not medically necessary to medically necessary for cancer survivors at risk for lymphedema
    • Annual Review updates to references
  • Powered Exoskeletal Robotic Systems
  • Rapid Platelet Function Assay
  • Ultra-Rapid Opiate Detoxification (UROD)
  • Measurement of Exhaled Nitric Oxide
  • Radioembolization for Primary and Metastatic Tumors of the Liver
  • Ambulance Services: Ground Transportation
  • Ambulance Services: Air and Water Transportation
  • Telehealth
  • Recombinant and Autologous Platelet Derived Growth Factors for Wound Healing and Other Non-Orthopedic   Conditions
  • In Vitro Allergy Testing
  • Vitamin D Assay
  • Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)
  • Laser Interstitial Thermal Therapy
  • Cardiac Contractility Modulation Therapy
  • Implantable Cardioverter Defibrillators
  • Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedure

The following medical policies had coding changes:

  • Heart/Lung Transplant
    • Removal of diagnosis codes I27.21 and I27.29
    • Added diagnosis codes J84.112, J84.178 and T86.32
  • Cranial Electrotherapy Stimulation and Auricular Electrostimulation
    • Removed HCPCS code K1002
    • Added E0732
  • Durable Medical Equipment
    • January new codes, removed HCPCS codes K1003 and K1013
    • Added HCPCS codes A4457 and E1301
  • Devices Used for the Treatment of Obstructive Sleep Apnea in Adults
    • January new codes removed HCPCS codes K1001, K1028, and K1029
    • Added new codes D9954, D9955, E0492, E0493, and E0530
  • Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions and Soft Tissue Wounds
    • January new code, added 0864T
  • Treatment of Abnormal Uterine Bleeding and Uterine Fibroids
    • January new codes: removed HCPCS code 0404T
    • Added procedure code 58580
  • Bariatric Surgery
    • January new codes: added HCPCS code 0813T
  • Foot Orthotics for Conditions other than Diabetes
    • January new codes: removed deleted code K1015
    • Added new HCPCS code L3161
  • Coronary Revascularization
    • January new codes: added HCPCS codes C7557 and C7558
  • Sacral Nerve Neuromodulation
    • January new codes: added HCPCS codes C7557 and C7558
  • Amniotic Membrane and Amniotic Fluid
    • January new codes: added Q4279, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, and Q4304
  • Vertebral Body Tethering
    • January new codes: added 0790T, 22836, 22837, and 22838
  • Cardiac Monitors
    • January new codes: removed deleted code G2066
  • Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy
    • January new codes: added 61889, 61891, and 61892
  • Bone Mineral Density Studies
    • January new codes: removed deleted code 0508T
  • Electrical Nerve Stimulation
    • January new codes: added new codes: 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 64596, 64597, 64598, 93151, 93152, 93153, A4541, A4542, E0733, E0734, and E0735
    • Removed deleted codes: 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, K1016, K1017, K1018, K1019, and K1020
    • Removed code E1399
  • Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
    • January new codes: added new code: D9956
  • Posterior Tibial Nerve Stimulation
    • January new codes: added new codes: 0816T, 0817T, 0818T, and 0819T
  • Experimental/Investigational
    • January new codes: added new codes: 31242, 31243, C1601, 92972, C9793, 0784T, 0785T, 0815T, 97037, 0811T, 0812T, 52284, E2001, 67516, 0820T, 0821T, 0822T, 0865T, 0866T, and E3000
    • Removed deleted codes: 0533T, 0534T, 0535T, 0536T, 0768T, 0769T, C9771, 0641T, 0642T, 0499T, 0465T and C9788
  • Lower Limb Prostheses
    • January new codes: added new codes L5615 and L5926
    • Removed deleted codes K1014 and K1022
  • Cochlear Implantation
    • January new codes: added new codes 92622 and 92623
  • Diagnosis and Treatment of Sacroiliac Joint Pain
    • January new codes: added new code 27278
    • Removed deleted codes: 0775T and 0809T
  • Occupational Therapy (OT)
    • January new codes: added new codes 97550, 97551, and 97552
  • Pneumatic Compression Devices
    • January new codes: added new codes E0680 and E0682
    • Removed deleted codes: K1024 and K1025
    • Removed diagnosis code I.87
    • E0652, E0671, E0672 and E0673 removed diagnosis logic
  • Proton Beam Therapy
    • January new codes: added new code C9794
    • Internal review added procedure code S8030
  • Intraperitoneal Chemotherapy
    • January New Codes added new codes 96547 and 96548 with covered diagnosis codes C16.0, C16.1, C16.2, C16.3, C16.4, C16.5, C16.6, C16.8, C16.9, C17.0, C17.1, C17.2, C17.2, C17.3, C17.8, C17.9, C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.56, C18.7, C18.8, C18.9, C19, C20, C21.0, C21.1, C21.2, C21.2, C21.8, C22.0, C22.14, C22.2, C22.3, C22.4, C22.7, C22.8, C22.9, C23, C24.0,C24.1, C24.8, C24.9, C26.0, C26.1, C26.9, C45.1, C48.0, C48.1, C48.2, C48.8, C56.1, C56.2, C56.3, C56.9, C57.0, C57.01, C57.10, C57.11, C57.12, C57.12, C57.20, C57.22, C57.3, C57.4, C57.7, C57.8, C57.9, C78.6, C79.60, C79.61, C79.52, and C79.63
  • Lung and Lobar Lung Transplant
    • Addition of diagnosis codes J84.112, J84.178 and T86.811
  • Cardiac Rehabilitation Programs, Phase II Outpatient
    • Added diagnosis codes: I09.89, I11.0, I13.0, I13.2, I21.B, I23.8, I24.81, I24.89, I24.9, I25.5, I25.6, I50.180, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, I50.89, I51.89, I51.9, I52, I73.9, I97.110, I97.111, I97.130, I97.131, I97.190, I97.191, Q20.3, T86.20, T86.21, T86.55, T86.23, T86.290, T86.298, T86.30, T86.31, T86.32, T86.33 and T86.3
    • Removed diagnosis codes: A18.84, I20.8, I25.3
  • Treatment of Benign or Premalignant Skin Conditions
    • Addition of 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, and 11313 to section for the treatment of Actinic Keratosis also found in 'removal of benign skin lesion
    • Added to covered diagnosis codes L56.8 and L57.0
  • Intraepidermal Nerve Fiber Density Testing
    • Removing procedure code 88342 as is it sent to eviCore for review
  • Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease
    • Removing procedure code 81401 as it is sent to eviCore for review
  • WATS3D Biopsy (EndoCDx)
    • Removing procedure code 88361 as it is sent to eviCore for review
  • Assisted Reproductive Technology
    • Removed procedure code 88182 as it is sent to eviCore for review
  • Surgical Treatment of Varicose Veins
    • Removed procedure codes 37735, 76998, 17106, 17107 and 17108
    • Procedure codes 17106, 17107 and 17108 are also found in policy S-28 Cosmetic Surgery vs Reconstructive Surgery (and are to remain there)
  • Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
    • Added covered diagnosis code N94.89 to procedure code 37241
  • Transcatheter Arterial Chemoembolization
    • Added procedure code 75894
  • Small Bowel/Liver and Multivisceral Transplant
    • Added diagnosis code K90.829
  • Surgical Treatment of Obstructive Sleep Apnea
    • Removed procedure codes 21122 and 21123
  • Miscellaneous
    • Removed procedure code 81506
  • Cosmetic and Reconstructive Surgery
    • Added procedure code J0591
  • Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
    • Added diagnosis codes S89.91XA, S89.91XS, S89.92XA, S89.92XD, and S89.92XS

The following medical policies will be archived / retiring:

  • Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
  • Cardiac Monitors
  • Transcatheter Aortic Valve Replacement
  • Ultrafiltration in Decompensated Heart Failure