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 November 29, 2022. To review our medical policy changes, visit our BCBSND website under medical policies.
The following medical policies are new:
- Hematopoietic Cell Transplantation: Solid Tumors
- Hospice
- For Medicaid Expansion (ME) only removed language from the commercial policy that was not applicable to ME
- Hematopoietic Cell Transplantation: Non-Cancer Diseases
- Rabies Vaccination and Immune Globulin
The following medical policies were revised:
- Electromagnetic Navigational Bronchoscopy (ENB)
- Changing experimental and investigative (E/I) statement to not medically necessary statement
- Prostate Disease: Diagnosis, Staging, and Treatment
- Minimal verbiage change, no change to criteria
- Liver Transplant
- Spelling out numerical values, no change to criteria
- Bone Mineral Density Studies
- adding the verbiage "or" in criteria
- Corneal Transplantation
- Change from E/I to not medically necessary
- Treatment of Benign or Premalignant Skin Condition
- Spelling out the abbreviation to full diagnosis
- Adding E/I statement
- Treatment of Malignant Skin Lesions
- Adding the verbiage "or" in criteria
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- Update / expand criteria
- Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
- Update / expand criteria
- Oxygen
- Adding: Bronchiolitis and RSV
- Intra-Arterial/Intravenous Therapeutic Procedures
- Update to language, no change to criteria
- Ultraviolet Light Therapies Ultraviolet Light Therapies
- Update to policy position / criteria
- Drug Testing
- Added a not medically necessary statement, criteria did not change
- Kidney Transplant
- Revising how a section of criteria is laid out, no change to criteria
- Diagnosis and Treatment of Sacroiliac Joint Pain
- The use of minimally invasive fusion products/implants other than SI BONE (iFuse Implant™ or iFuse-3D Implant ™) System is considered investigational.
- Intraperitoneal Chemotherapy
- Revising how a section of criteria is laid out, no change to criteria
- Meniscal Allografts and Other Meniscal Implants
- Addition of summary of evidence
- Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
- Addition of summary of evidence
- Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest
- Addition of summary of evidence
- was: Intensity-Modulated Radiotherapy: Abdomen and Pelvis
- References added
- Minor editorial refinements to policy statements
- Intensity-Modulated Radiotherapy of the Breast and Lung
- Addition of summary of evidence
- References added
- Minor editorial refinements to policy statements
- Intensity-Modulated Radiotherapy of the Prostate
- Addition of summary of evidence
- References added
- Minor editorial refinements to policy statements
- Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
- Addition of summary of evidence
- References added
- Intensity-Modulated Radiotherapy: Central Nervous System Tumors
- Addition of summary of evidence
The following medical policies are consent policies:
- Lung and Lobar Lung Transplant
- External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
- Transcatheter Arterial Chemoembolization
- Transcatheter Aortic Valve Replacement (TAVR)
- Heart/Lung Transplant
- Thermography (Thermogram)
- Frenectomy or Frenotomy for Ankyloglossia
- Radiofrequency Facet Denervation
- Total Ankle Replacement
- Nerve Conduction Studies and Electromyography
- Fetal Surgery for Prenatally Diagnosed Malformations
- Endoscopic Stricturotomy
- Seat Lift Mechanisms
- Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (LINX®)
- Desensitization Treatment for Heart and Renal Transplant
- Magnetic Resonance Imaging (MRI) of the Breast
- Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
- Respiratory Assist Devices
- Ablation of Liver Tumors
- Non-spinal Bone Growth Stimulation
- Subtalar Arthroereisis
- Foot Orthotics for Conditions Other Than Diabetes
- Ambulatory Blood Pressure Monitoring
- Biofeedback
The following medical policies had coding changes:
- Bone Mineral Density Studies
- Update to diagnosis codes
- Adding new codes: 0743T, 0749T, 0750T
- Allergy Skin Testing
- Update to diagnosis codes
- Small Bowel, Small Bowel/Liver and Multivisceral Transplant
- Update to diagnosis codes
- Corneal Transplantation
- Update to diagnosis codes
- Treatment of Benign or Premalignant Skin Condition
- Update diagnosis code
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- Removing codes: 64568, 64569, 64570
- Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
- Removing codes: 64568, 64569, 64570
- Ultraviolet Light Therapies Ultraviolet Light Therapies
- Update to diagnosis codes
- Drug Testing
- Update to diagnosis codes
- Physical Therapy (PT)
- Removing codes: 99339 and 99340
- Occupational Therapy (OT)
- Removing codes: 99339 and 99340
- Bioengineered Skin and Soft Tissue Substitutes
- Removing code: C1849
- Amniotic Membrane and Amniotic Fluid
- Adding new codes: Q4262, Q4263, Q4264
- Coronary Revascularization
- Adding new codes: C7552, C7553
- Deep Brain Stimulation
- Adding new code: C1826
- Electrical Nerve Stimulation
- Adding new codes: C1826
- Intra-Arterial/Intravenous Therapeutic Procedures
- Adding new codes: C7513, C7514, C7515, C7530, C7532
- Bariatric Surgery
- Adding new codes: 43290, 43291
- Removing codes: 0312T, 0313T, 0314T, 0315T, 0316T, 0317T
- Fecal Microbiota Transplantation
- Removing code: 44799
- Adding code: 0780T
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Remove diagnosis code: M54.5
- Add diagnosis codes: M54.50-M54.59
- Add code: 0775T, specific to ND not in association policy
- Prostate Disease: Diagnosis, Staging, and Treatment
- Adding new code: 55867
- Intraperitoneal Chemotherapy
- Update diagnosis codes
- Ostomy Supplies
- Experimental-Investigational Services
- Addition of multiple new codes effective 1/1/2023
- Mastectomy and Reconstructive Surgery
- Adding code: 19371
- Artificial Intervertebral Disc Replacement
- Adding code: 22860
- Telehome Monitoring
- Adding code: G0322
The following medical policies will be archived / retiring:
- Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
- Will be archived, will now be part of S-273 (new policy effective 1/2/2023)
- Hematopoietic Cell Transplantation for Solid Tumors of Childhood
- Will be archived, will now be part of S-273 (new policy effective 1/2/2023)
- Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors
- Will be archived, will now be part of S-273 (new policy effective 1/2/2023)
- Hematopoietic Cell Transplantation for Autoimmune Diseases
- Will be archived, will now be part of S-274 (new policy effective 1/2/2023)
- Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemia
Will be archived, will now be part of S-274 (new policy effective 1/2/2023)
