Medical Policies Available Online Updates

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 Nov. 15, 2023. To review our medical policy changes, visit our BCBSND website under medical policies.

The following medical policies are new:

  • Manipulation Services (Medicaid Expansion only)

The following medical policies were revised:

  • Wearable Cardioverter-Defibrillator
    • Updated verbiage to include: ‘and anyone of the following criteria’ to second bullet under criteria
  • Islet Cell Transplantation
    • New coverage criteria added
    • References updated
  • Thermoplasty (Thermogram)
    • Professional Statement section updated, removed previous statements, and added National Comprehensive Cancer Network
  • Intensity-Modulated Radiotherapy of the Prostate
    • References were updated
  • Prostate Disease: Diagnosis, Staging, and Treatment
    • Removed bullet from the treatment for BPH: prostatic arterial embolization
  • Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
    • References updated
  • Devices and Audiological Testing
    • References updated
  • Ultraviolet Light Therapies
    • Punctuation corrections made
  • Manipulation Services
    • Made Commercial only with the development of Medicaid Expansion policy
    • Grammatical errors corrected
  • Peer Support
    • Grammatical changes made, change 'Anyone' to 'At least one (1)' and removed statement: The member is not at imminent risk of serious harm to self or others.'

The following medical policies are consent policies:

  • Tumor Markers
  • Foot Care Services
  • Clinical Trials
  • Oxygen
  • Rabies Vaccination and Immune Globulin
  • Nerve Conduction Studies and Electromyography
  • Electromagnetic Navigational Bronchoscopy (ENB)
  • Telehome Monitoring for Congestive Heart Failure and/or Chronic Obstructive Pulmonary Disease
  • Treatment of Malignant Skin Lesions
  • Intra-Arterial/Intravenous Therapeutic Procedures
  • Transcatheter Arterial Chemoembolization
  • Corneal Transplantation
  • Ablation of Liver Tumors
  • Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
  • Transcatheter Aortic Valve Replacement (TAVR)
  • Hematopoietic Cell Transplantation: Solid Tumors
  • Frenectomy or Frenotomy for Ankyloglossia
  • Magnetic Resonance Imaging (MRI) of the Breast
  • Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest
  • Intensity-Modulated Radiotherapy: Central Nervous System Tumors
  • Powered Exoskeletal Robotic Systems
  • Pancreas Transplant
  • Occupational Therapy
  • Radiofrequency Facet Denervation
  • Diabetic Services and Supplies
  • Polysomnography (PSG) for Non-Respiratory Sleep Disorders
  • Ostomy supplies

The following medical policies had coding changes:

  • Durable Medical Equipment
    • Added diagnosis codes (from Oct. 2023 new codes) for procedure codes A6410, A6411, and A6412: H50.621, H50.622, H50.629, H50.631, H50.632, H50.639, H50.641, H50.642, H50.649, H50.651, H50.652, H50.659, H50.661, H50.662, H50.669, H50.671, H50.672, H50.679, H50.681, H50.682, and H50.689
    • Add procedure code K1036 (from Oct. 2023 new codes)
  • Bioengineered Skin
    • Added procedure codes A2024 and A2025 (from Oct. 2023 new codes) at section: ‘ALL other skin and soft tissue substitutes not listed above are considered experimental/investigational.’
  • Treatment of Benign or Premalignant Skin Conditions
    • Removed diagnosis code D48.1 (from Oct. 2023 new codes) from section: Covered diagnosis codes for procedure codes 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11444, 11446, 17110, and 17111
  • Small Bowel, Small Bowel/Liver and Multivisceral Transplant
    • Added diagnosis codes (from Oct. 2023 new codes): K90.821, K90.822, K90.829, and K90.83
  • Cardiac Rehabilitation Programs, Phase II Outpatient
    • Added diagnosis codes (from Oct. 2023 new codes) I20.81, I 20.89, and I24.89 to procedure codes 93797, 93798, G0422, and G0423                     
  • Respiratory Assist Devices
    • Added diagnosis code (from Oct. 2023 new codes) J44.89
  • Heart/Lung Transplant
    • Added diagnosis code (from Oct. 2023 new codes) J44.89
  • Electroencephalogram
    • Added diagnosis codes (from Oct. 2023 new codes) E88.43, G23.3, G37.81, G37.89, G93.42, G93.43, and G93.44   
    • Removed diagnosis codes: G20 and G37.8         
  • Cranial Orthosis for Plagiocephaly
    • Added diagnosis codes (from Oct. 2023 new codes) to S1040:
      • Q75.001, Q75.002, Q75.009, Q75.01, Q75.01, Q75.021, Q75.022, Q75.029, Q75.03, Q75.041, Q75.042, Q75.049, Q75.051, Q75.52, Q75.058, and Q75.08  
    • Remove diagnosis from S1040: Q75.0                  
  • Wheelchairs (WC) and Options/Accessories
    • Added diagnosis codes (from Oct. 2023 new codes) G20.A1, G20.A2, G20.B1, G20.B2, G20.C to procedure codes E2230 and E2301
    • Removed diagnosis code G20 from procedure codes E2230 and E2301                      
  • Devices Used for the Treatment of Obstructive Sleep Apnea in Adults
    • Added procedure codes (from Oct. 2023 new codes) E0490 and E0491 to Daytime Electrical Stimulation Devices section
  • Outpatient Pulmonary Rehabilitation
    • Added diagnosis code (from Oct. 2023 new codes) J44.89
  • Ultrasound Osteogenesis Stimulator
    • Added diagnosis codes (from Oct. 2023 new codes) to procedure codes 20979 and E0760: M80.0B1A, M80.0B1D, M80.0B1G, M80.0B1K, M80.0B1P, M80.0B1S, M80.0B2A, M80,0B2D, M80.0B2G, M80.0B2K, M80.0B2P, M80.0B2S, M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B1A, M80.8B1D, M80.8B1G, M80.8B1K, M80.8B1P, M80.8B1S, M80.8B2A, M80.8B2D, M80.8B2G, M80.8B2K, M80.8B2P, M80.8B2S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, and M80.8B9S
  • Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
    • Added diagnosis codes (from Oct. 2023 new codes) G93.42, G93.43, and G93.44
  • Bone Mineral Density Studies
    • Added diagnosis codes (from Oct. 2023 new codes) to procedure codes 77078, 77080,  77081, M80.0B1A, M80.0B1D, M80.0B1G, M80.0B1K, M80.0B1P, M80.0B1S, M80.0B2A, M80,0B2D, M80.0B2G, M80.0B2K, M80.0B2P, M80.0B2S, M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B1A, M80.8B1D, M80.8B1G, M80.8B1K, M80.8B1P, M80.8B1S, M80.8B2A, M80.8B2D, M80.8B2G, M80.8B2K, M80.8B2P, M80.8B2S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, and M80.8B9S
  • Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
    • Added new diagnosis code (from Oct. 2023 new codes) D13.91 and D13.99 to procedure codes 91110 and 91111
    • Type noted: diagnosis code Q85.59 change to Q85.89
  • External Counterpulsation (ECP)
    • From Oct. 2023 new codes
    • Added diagnosis codes I20.81 and I230.89 to procedure code G0166
    • Removed diagnosis code I20.8 from procedure code G0166                      
  • Autonomic Nervous System Function Testing
    • Added diagnosis codes (from Oct. 2023 new codes) to procedure codes 95921, 95922, 95923, and 95924: G23.3, I47.11, and I47.19
  • Lower Limb Prostheses
    • Added diagnosis code from Oct. 2023 new codes: L5991
  • Hematopoietic Cell Transplantation: Non-Cancer Diseases
    • Added diagnosis code from Oct. 2023 new codes to procedure codes 38205, 38230, 38240, S2140, S2142, and S2150: D48.110, D48.111, D48.112, D48.113, D48.114, D48.115, D48.116, D48.117, D48.118, D48.119, D57.04, D57.214, D57.414, D57.434, D57.454, D61.02, G31.80, and G90.B
  • Cardiac Monitors
    • From Oct. 2023 new codes added diagnosis codes I20.81, I20.89, I21.B, I47.10, and I14.11 to procedure codes 93228, 93229, 93268, 93270, 93271, and 93272. Added diagnosis codes I20.81, I20.89, I21.B, and I24.89 to procedure codes 93228 and 93229
    • Removed diagnosis codes I21.8 and I47.1 from procedure codes 93228, 93229, 93268, 93270, 93271, 93272, 93228 and 93229
    • Added HCPCS code C1764 
  • High Frequency Chest Wall Oscillation Devices
    • Added diagnosis J44.89 (from Oct. 2023 new codes)                        
  • Wearable Cardioverter-Defibrillator
    • From Oct. 2023 new codes, diagnosis codes I47.10, I47.11 and I47.19 were added and I47.1 was removed                      
  • Liver Transplant
    • From Oct. 2023 new codes, added diagnosis codes Q44.70, Q44.71 and Q44.79. Removed diagnosis code Q44.7
  • Heart Transplantation Adult and Pediatric
    • From Oct. 2023 new codes/deleted codes, removed I47.1
  • Deep Brain Stimulation
    • From Oct. 2023 new codes/deleted codes, added G20.A1, G20.A2, G20.B1, G20.B2, and G20.C; and removing G20
  • Electroretinography
    • From Oct. 2023 new codes added H36.812, H32.812, H36.813, H36.819, H36.821, H36.822, H36.823, H36.829, and H36.89
  • Nebulizers
    • Added new diagnosis codes (from Oct. 2023 new codes): J15.61, J15.69, and J44.89; Removed diagnosis code J15.6
  • Cardiac Ablation Procedures
    • From Oct. 2023 new codes, removed diagnosis code I47.1 from procedure codes 93613, 93650, 93653, 93655, 93656, 93657, 33254, 33255, 33256, 33257, 33258 and 33259. Added diagnosis codes I47.10, I47.11, I47.19 to procedure codes 93650, 93653, 93655, 93656, 93657, 33254, 33255, 33256, 33257, 33258 and 33259
  • Ambulatory Blood Pressure Monitoring
    • Added the following diagnosis codes (from Oct. 2023 new codes): I1A.0, I20.81, I20.89, M32.10, M32.11, M32.12, M32.13, M32.145, M32.15, M32.19, M32.8, M32.9, Q93.52, Z94.0, Z94.1, Z94.2, Z94.3, Z94.4, Z94.82, Z94.83 and removed I20.8
  • Electrical Nerve Stimulation
    • Added new diagnosis codes (from Oct. 2023 new codes) G40.C01, G40.C09, C40.C11, and G40.C19 to procedure codes 61885, 61886, 64553, 64568, 64569, and 64570                       
  • Experimental/Investigational
    • Added new procedure codes A9268, A9269, C9790, and C9788 (from Oct. 2023 new codes)
    • Added procedure codes A9291 and A9292
  • Amniotic Membrane and Amniotic Fluid
    • Added diagnosis (from Oct. 2023 new codes) A2022, A2023, Q4285, and Q4286                       
  • Pheresis Therapy
    • From Oct. 2023 new codes added diagnosis codes: D57.04, D57.24, D57.414, D57.434, D57.454, D57.814 to procedure code 36522, 36511, 36516, and S2120 and removed diagnosis code N06.2 from procedure codes 36512, 36513, 36514, and 36511
  • Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
    • Added diagnosis code I1A0 to Covered diagnosis code for procedure codes 95807, 95808, 95810, and 95811
  • Coronary Revascularization
    • Removed diagnosis code I20.8
    • Added procedure codes 33210, 33211, 93024, 93451, 93452, 93453, 93456, 93457, 93458, 93459, 934690, 93461, 93462, 93593, 93594, 93595, 93596, and 93597
  • Cognitive Rehabilitation
    • Added diagnosis codes G93.42, G43.43, and G93.44
  • Islet Cell Transplantation
    • Added procedure codes J3490, J3590 and C9399 and covered dx codes E10.10, E10.11, E10.21, E10.22, E10.29, E10.35, E10.36, E10.40, E10.41, E10.42, E10.44, E10.61, E10.62, E20.63, E10.64, E10.65, E10.69, E10.8, and E10.9 for procedure codes J3490, J3590 and C9399
  • Transcatheter Closure Devices for Septal Defects
    • Added procedure code 93662 (Intracardiac echocardiography during therapeutic/diagnostic intervention)
  • Desensitization Treatment for Heart and Renal Transplant
    • Added procedure code Q5123
  • Corneal Topography/Computer-Assisted Corneal Topography/ Photokeratoscopy
    • Removed the following non-covered diagnosis codes: H18.711, H18.712, H18.713, H18.621, H18.622, H18.623, H18.611, H18.612, H18.613, H18.601, H18.603, H18.451, H18.452, H18.453, H18.461, H18.462, H18.463, H18.40, H18.10, H18.11, H18.12, H18.13, H18.421, H18.422, H18.423, H18.821, H18.822, and H18.823
  • Physical Therapy (PT)
    • Added payable diagnosis codes R65.50 and R26.90 to Procedure code 97116
  • Prostate Disease: Diagnosis, Staging, and Treatment
    • Removed procedure code 37243 from experimental/investigational
  • Meniscal Allografts and Other Meniscal Implants
    • Added HCPCS code G0428
  • Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
    • Removed invalid diagnosis code C00.7
    • Added diagnosis code C06.0 and HCPCS codes G6015 and G6016
  • Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
    • Added the following diagnosis codes: I63.09, I63.111, I63.112, I63.1413, I63.119, I36.131, I63.132, I63.133, and I63.139
    • Removed the following diagnosis codes: 163.11 and 163.13 (needs 6th digit)
  • Manipulation Services
    • Removed HCPCS code S8890 and added S8990
      • Commercial only-S8890 invalid code, correcting to S8990
  • Lung and Lobar Lung Transplant
    • Added diagnosis codes J44.81 and J44.89(from Oct. 2023 new codes)
  • Foot Care Services
    • Removed diagnosis codes S96.109A and S96.199A from procedure codes 11055, 11056, 11057, 11720, 11721, 11719, 97022, G0127, G0245, G0246, G0247, and S0390

The following medical policies will be archived / retiring:

  • Impedance Cardiography in Hypertension
  • Total Ankle Replacement