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 September 28, 2022. To review our medical policy changes, visit our BCBSND website under medical policies.
The following medical policies were revised:
- Electronystagmography and Videonystagmography Services
- Changing the not meeting criteria statement
- Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents
- Minimal verbiage changes, ie 3 to three
- Amniotic Membrane and Amniotic Fluid
- Rewording of the not medically necessary statements
- Percutaneous Vertebroplasty and Sacroplasty
- Added summary of evidence and updated references
- Tumor Treatment Fields
- Changed the layout of the medical policy, no change to criteria.
- Diagnosis and Treatment of Male Sexual Dysfunction
- Following was removed from male sexual dysfunction:
- Collagenase clostridium histolyticum injection (e.g., Peyronie’s disease).
- Removed because it has specific criteria within Injectable Collagenase Clostridium Histolyticum (Xiaflex), i.e. Treatment of Peyronie's Disease
- Following was removed from male sexual dysfunction:
- Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
- Removed this statement: no longer considers it E/I:
- IONM of motor-evoked potentials using transcranial magnetic stimulation is considered experimental/investigational and therefore, non-covered because the safety and/ or effectiveness of this service cannot be established by the available peer-reviewed literature.
- Removed this statement: no longer considers it E/I:
- Cranial Orthosis for Plagiocephaly
- Removed:
- Cranial orthosis is considered cosmetic and therefore non-covered when used in the treatment of non-synostotic plagiocephaly with mild deformity and/or when a minimum trial period of two (2) months of conservative therapy has not been tried.
- Removed:
- Treatment of Hyperhidrosis
- removing criteria: Botulinum toxin A (OnabotulinumtoxinA) for severe primary axillary hyperhidrosis that is inadequately managed with topical agents, in individuals 18 years and older; or
- this criteria is in the botox policy
- Ablation of Miscellaneous Solid Tumors
- Changing 12 to TWELVE
- Allergy Immunotherapy
- Adding a not medically necessary statement
- Oncologic Applications of Positron Emission Tomography Scanning
- Now coverage for prostate cancer
The following medical policies are consent policies:
- Intracellular Micronutrient Testing Panel
- Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
- Powered Exoskeletal Robotic Systems
- Myoelectric Prosthetic Components for the Upper Limb
- Lower Limb Prostheses
- Polysomnography (PSG) for Non-Respiratory Sleep Disorders
- Telehome Monitoring
- Transcatheter Pulmonary Valve Implantation
- Implantable Pulmonary Artery Pressure Measurement Device
- Sacral Nerve Neuromodulation
- Gastric Electrical Stimulation, Gastric Pacing
- Ankle-Foot/Knee-Ankle-Foot Orthosis
- Ambulatory and Outpatient Cardiac Hemodynamic Monitoring of Heart Failure
- Chronic Pain Programs
- H-wave Electrical Stimulation
- Interferential Stimulator
- High Frequency Chest Wall Oscillation Devices
- Functional Neuromuscular Electrical Stimulation
- Clinical Trials
- Pneumatic Compression Devices
- Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
- Enteral Nutrition
- AposTherapy System
The following medical policies had coding changes:
- Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
- Treatment of Hyperhidrosis
- Coronary Revascularization
- Transcatheter Mitral Valve Repair/Replacement
- Wearable Cardioverter-Defibrillator
- Cardiac Rehabilitation Programs, Phase II Outpatient
- Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
- Cardiac Ablation Procedures
- External Counterpulsation (ECP)
- Autonomic Nervous System Function Testing
- Cardiac Monitors
- Cranial Electrotherapy Stimulation and Auricular Electrostimulation
- Artificial Hearts and Ventricular Assist Devices
- Transcatheter Closure Devices for Septal Defects
- Electroencephalogram
- Esophageal pH Monitoring
- Pheresis Therapy
- Heart Transplantation Adult and Pediatric
- Bioengineered Skin and Soft Tissue Substitutes
- Cognitive Rehabilitation
- Chelation Therapy for Off-Label Uses
- Allergy Immunotherapy
- Experimental/Investigational Services
- Beds- Accessories and Related Items
- Oncologic Applications of Positron Emission Tomography Scanning
The following medical policies will be archived / retiring
