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 March 23, 2023, and will be updated within the next 15-30 days. Please review the policy as some policies have different effective dates.
To review our medical policy changes, visit our BCBSND website under medical policies.
The following medical policies are new:
- Lipedema
- Hepatobiliary System Imaging
- Covid-19 Antibody Testing
The following medical policies were revised:
- Spinal Cord and Dorsal Root Ganglion Stimulation
- Added Summary of Evidence
- Added References
- Manipulation Services
- Removed Evaluation and Management (E/M) Services as it is now going to be in a reimbursement policy
- Effective 4/15/2023
- Heart Transplantation Adult and Pediatric
- Added "OR" to criteria section for clarification
- Assisted Reproductive Technology
- Added language to clarify language for voluntary sterilization.
- Added language to clarify Frozen Embryo Transfer (FET).
- Bariatric Surgery
- New Criteria: Laparoscopic adjustable banding is an eligible procedure ONLY when a contraindication to biliopancreatic bypass with duodenal switch, Rou-en-Y gastric bypass, and sleeve gastrectomy is documented in the medical record.
- Added criteria for BMI of 35 kg: coronary heart disease (with objective documentation (by exercise stress test, radionuclide stress test, pharmacologic stress test, stress echocardiography, CT angiography, coronary angiography, heart failure, or prior myocardial infarction)
- Added criteria for BMI of 35 kg: Pseudotumor Cerebri
- External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
- Added over the counter (OTC) hearing aid (amplifier) as non-covered
- Wheelchairs (WC) and Options/Accessories
- Added OTC hearing aid (amplifier) as non-covered V5274. specific to ND
- Oncologic Applications of Positron Emission Tomography (PET) Scanning
- Revision to Penile section and removed the staging definitions
- Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
- Changed a not medically necessary statement to E/I
- Added summary of evidence
- Updated references
- Minor editorial refinements
- Chromoendoscopy as an Adjunct to Colonoscopy
- Added summary of evidence
- Updated references
- Measurement of Serum Antibodies to Selected Biologic Agents
- Added summary of evidence
- Laminectomy
- Added summary of evidence
- Updated references
- Hip Resurfacing
- Added summary of evidence
- Updated references
- Spinal Cord and Dorsal Root Ganglion Stimulation
- Added summary of evidence
- Updated references
- Axial Lumbosacral Interbody Fusion
- Added summary of evidence
- Monitored Anesthesia Care
- References added
- Added summary of evidence
- Not medically necessary language changed to investigational.
- Other minor editorial refinements
- Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease
- References added
- Added Summary of evidence
The following medical policies are consent policies:
- Deep Brain Stimulation
- Osseointegrated Dental Implants
- Ultrasound Osteogenesis Stimulator
- Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
- Endoscopic Radiofrequency Ablation/Cryotherapy
- General Anesthesia for Oral and Maxillofacial Surgery and Dental Services
- Prophylactic Mastectomy
- Eustachian Tube Balloon Dilation
- High Frequency Chest Wall Oscillation Devices
- Wearable Cardioverter-Defibrillator
- Tumor Treatment Fields
- Ankle-Foot/Knee-Ankle-Foot Orthosis
- Miscellaneous Services
- Deep Brain Stimulation
- Electrical Nerve Stimulation
- Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy
- Intraperitoneal Chemotherapy
- Photography
- Transcutaneous Transducer Garments
- Electric Breast Pumps
- Repair, Maintenance, and Replacement of Durable Medical Equipment (DME)
- Digital Imaging Systems for the Detection and Evaluation of Diabetic Retinopathy and Intraocular Photography
- Speech Generating Devices
- Home Cervical Traction Therapy
- Electroretinography
- Intraocular Lens
- Hematopoietic Cell Transplantation: Experimental/Investigational Services
- Orthopedic Applications of Stem-Cell Therapy
- Confocal Laser Endomicroscopy
- Dynamic Splinting Devices
The following medical policies had coding changes:
- Manipulation Services
- Removed codes: 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99417
- Effective 4/15/2023
- Gender Affirmation Surgery
- Added Codes: 21125, 21127, 21137, 21138, 21139
- Removed: 19301, 54530, 54535, 54692, 57106, 57107, 21183, 30462, 21184, 30465, 21181, 30460
- Cosmetic and Reconstructive Surgery
- Adding codes: 21137, 21138, 21139
- Coronary Revascularization
- Removed code 93543
- Allergy Skin Testing
- Updated 2 diagnosis (Dx) codes
- Treatment of Benign or Premalignant Skin Conditions
- Updated 2 payable Dx codes
- Seat Lift Mechanisms
- Removal of deleted code E0628
- Pulmonary Rehabilitation (HMK is Outpatient Pulmonary Rehabilitation)
- Removal of deleted codes 97001 97002
- External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
- Added V5274
- Drug Testing
- Added additional covered Dx codes as covered for 80307:
- F32.9 Major depressive disorder, single episode, unspecified
- F32.A Depression, unspecified
- F41.1 Generalized anxiety disorder
- F41.9 Anxiety disorder, unspecified
- F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
- F90.2 Attention-deficit hyperactivity disorder, combined type
- F98.8 Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence
- R45.851 Suicidal ideations
- B18.2 Chronic viral hepatitis C
- B17.10 Acute hepatitis C without hepatic coma
- F32.9 Major depressive disorder, single episode, unspecified
- F32.A Depression, unspecified
- F41.9 Anxiety disorder, unspecified
- F15.11 Other stimulant abuse, in remission
- Added additional covered Dx codes as covered for 80307:
- Electroencephalogram
- Updated Dx codes
- Amniotic Fluid and Amniotic Membrane
- New Codes Effective 4/1/2023: Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271
- Bioengineered Skin and Soft Tissue Substitutes
- New Codes Effective 4/1/2023: 4/1/2023: A2019, A2020, A2021
- Devices Used for Treatment of Obstructive Sleep Apnea in Adults
- New Code Effective 4/1/2023: A7049
- Allergy Immunotherapy
- Updated Dx coding logic, removing 1 Dx code
- Urological Supplies
- New Code Effective 4/1/2023: A4341 AND A4342
- Measurement of Serum Antibodies to Selected Biologic Agents
- Added codes: 80299, 82397 and 83520
- Laminectomy
- Added codes: 63271, 63276, 63281, 63286
- Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography
- Updating Dx codes
- Sacral Nerve Neuromodulation
- Added New Code L8678 effective 4/1/2023
- Experimental-Investigational
- Removed deleted codes
The following medical policies will be archived / retiring:
- Artificial Hearts and Ventricular Assist Devices
