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 our Internal Medical Policy Committee on May 14, 2024, and will be updated within the next 30 days. These changes apply to both our Commercial and Medicaid Expansion policies unless noted.

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

The following medical policy is new:

  • Transanal Irrigation


The following medical policies were revised:

  • Manipulation Services (Medicaid Expansion only)
    • Added new verbiage under criteria.
  • Surgical Treatment of Obstructive Sleep Apnea
    • Annual review with criteria updated.
  • Occupational Therapy (OT)
    • Annual review criteria update, language clarification and operational guidelines updated.
  • Repair, Maintenance, and Replacement of Durable Medical Equipment (DME)
    • Removed 'and chest x-ray' from Lung cancer section under criteria.
  • Pain Management by Injection
    • Annual review with verbiage/clerical updates.
  • Devices Used for the Treatment of Sleep Apnea in Adults:
    • Removed sentence: Throughout the Positive Airway Pressure (PAP) device rental period, the DME supplier must check that the member is compliant with use of the device. If the device is not being used as prescribed, the DME supplier should contact the individual's physician and discuss removal of the device. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental.
  • Beds Accessories and Related Items:
    • Statement changed from not medically necessary to non-covered (Safety bed section, E1399).
  • Oncologic Applications of Positron Emission Tomography Scanning
    • Removed 'and chest x-ray' from Lung cancer section under criteria.
  • Outpatient Pulmonary Rehabilitation
    • Changes made to operational guidelines.
  • Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
    • Added Minute Man Procedure.
  • Per-Oral Endoscopic Myotomy (POEM)
    • Added POEM for treatment of achalasia and Gastric POEM (G-POEM) with criteria.
  • Ligation or Ablation, Incompetent Perforator Veins
    • Criteria updated to include endovenous laser ablation.
  • Surgical Treatment of Varicose Veins
    • Criteria grid updated.
  • Remote Patient Monitoring (RPM) (Previously: Telehome Telemonitoring for Chronic Disease)
    • Title change and criteria updated.
    • Removed portion of criteria for one or more of the following reasons: Recent hospitalization in the last 6 months, A history of failing to adhere to their treatment plan and are at risk of an acute episode, multiple (greater than 2) emergency room visits in the last six months.
  • Cervical Fusions
    • Updates to Professional Statement section.
  • Measurement of Serum Antibodies to Selected Biologic Agents
    • Updates to Professional Statement section.
  • External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
    • Changes to Quantity Level Limits (QLL): Processor replacement two (2) per five (5) years and added QLL for hearing aids of one (1) per three (3) years.
  • Allergy Immunotherapy
    • Addition of Quantity Level Limits (QLL) of 150 doses/units for the first year, including build up phase. Changed QLL of 120 doses/units for after the first year as maintenance therapy.


The following medical policies are consent policies:

  • Osseointegrated Dental Implants
  • General Anesthesia for Oral and Maxillofacial Surgery and Dental Services
  • Patient Lifts
  • Speech Generating Devices
  • Non-Powered Negative Pressure Wound Therapy System
  • Home Cervical Traction Therapy
  • Homocysteine Testing in the Screening, Diagnosis, & Management of Cardiovascular Disease & Venous Thromboembolic Disease
  • Biofeedback
  • Noninvasive Techniques for the Evaluation & Monitoring of Patients with Chronic Liver Disease
  • Covid-19 Antibody Testing
  • Digital Imaging Systems for the Detection and Evaluation of Diabetic Retinopathy and Intraocular Photography
  • Transcutaneous Transducer Garments
  • Electric Breast Pumps
  • Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
  • Myocardial Strain Imaging
  • Cerebral Oxygenation Monitoring using Near Infrared Spectroscopy (NIRS)
  • Chromoendoscopy as an Adjunct to Colonoscopy
  • Kidney Transplant
  • Endoscopic Radiofrequency Ablation/Cryotherapy
  • Ilizarov Bone Lengthening
  • Discography
  • Eustachian Tube Balloon Dilation
  • Acellular Dermal Matrix Grafts
  • Orthopedic Applications of Platelet-Rich Plasma
  • Leadless Cardiac Pacemaker
  • Hematopoietic Cell Transplantation: Experimental/Investigational Services
  • Hip Resurfacing
  • Axial Lumbosacral Interbody Fusion
  • Laminectomy
  • Surgical Treatments for Breast Cancer-Related Lymphedema
  • Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
  • Photography
  • Composite Tissue Allotransplantation of the Hand
  • Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
  • Hematopoietic Cell Transplantation: Blood Cancers
  • Ocular Photodynamic Therapy (PDT)
  • Home Pulse Oximetry Device
  • Pap Smears with Medical Conditions
  • Proton Beam Radiation Therapy (Benefit plans FM Home Builders Consortium and Eide Bailly only)


The following medical policies had coding changes:

  • Monitored Anesthesia
    • Removed deleted procedure code 01936 and added diagnosis codes 01937, 01938, 01939, 01940, 01941 and 0942.
    • Removed the following diagnosis codes: C16, C17, C18, C22, C24, C25, C26, C34.1, C34.8, C34.9, D01.4, D13, D13.3, D13.9, G89.1, G89.2, G90.51, G90.52, J41, J43, J44, J45, J45.2, J45.3, J45.4, J45.5, J45.9, J45.90, J45.99, J47, J96, J96.1, J96.2, J96.9, J98, J98.0, J98.1, J95.5, K80.1, K80.2, K80.3, K80.4, K80.5, K80.6, K80.7, K80.8, K81, K82, K82.A, K83, K85.0, K85.1, K85.2, K85.3, K85.8, K85.9, K86, K86.8, M25.51, M25.52, M25.53, M25.54, M25.55, M25.57, M54.3, M54.4, M54.5, M54.8, M79.60, M79.62, M79.63, M79.64, M79.65, M79.66, M79.67, Z12.2, Z83.71, Z85.02, Z85.03 and Z85.04. o Added diagnosis codes: J44.81, J44.9, M25.552, M25.261, M25.562, M54.08, M54.09, M54.10, M54.11, M54.12, Z12.0, Z83.710, Z83.711, Z83.718, Z83.719, Z85.07 and Z85.09.
  • Manipulation Services (Medicaid Expansion only)
    • Removed procedure codes 95851,95852, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97036, 97110, 97112, 97113, 97116, 97124, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97763, 98925, 98926, 98927, 98928, 98929, G0283 and S8950.
    • Added procedure codes 99202; 99203, 99211, 99212 and 99213.
  • Occupational Services
    • Removed procedure code 97533 and diagnosis codes.
  • Pain Management by Injection
    • Removal of unspecified side diagnosis codes: G57.50, G57.60, G57.80 and G57.90.
  • Seat Lift Mechanisms
    • Added diagnosis codes G10.0, G12.20, G12.22, G12.23, G12.24, G12.25, G20, G20.B2, G35, G70.00, G70.01, G70.1, G70.2, G70.80, G70.81, G70.89, G73.1 and G73.3.
    • Added diagnosis codes M05.551, M05.552, M05.561, M05.562, M05.651, M05.652, M05.661, M05.662, M05.751, M05.752, M05.761, M12.151, M12.152, M12.161, M12.162, M12.551, M12.552, M12.561, M12.562, M12.851, M12.852, M12.861, M12.862, M13.851, M13.852, M13.861, M13.862, M15.0, M15.1, M15.2, M15.3, M15.4, M15.8, M16.0, M16.11, M16.12, M16.31, M16.32, M16.4, M16.51, M16.52, M16.6, M16.7, M17.0, M17.11, M17.12 and M35.3.
  • Bone Mineral Density Studies
    • Added 77090, 77091, and 77092 to Covered Diagnosis Codes for procedure codes and added specific diagnosis codes for 77080 and 77081.
  • Speech Therapy
    • Added 92526, 92597, 92607, 92608, 92609, 92610, 92611, 96125, 97032, 97129, 97130 and 97799 to habilitative section.
  • Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
    • Added procedure code 22612.
  • Per-Oral Endoscopic Myotomy (POEM)
    • Adding procedure code 43499 with diagnosis code K31.84.
  • Ligation or Ablation, Incompetent Perforator Veins
    • Added procedure codes 36478 and 36479.
  • Surgical Treatment of Varicose Veins
    • Removed procedure codes 36478 and 36479.
  • Remote Patient Monitoring (RPM) (Previously: Telehome Telemonitoring for Chronic Disease)
    • Added procedure codes 99453, 99454, 99457, 99458, 99473, 99474, 98975, 98976, 98977, 98978, 98980 and 98981.
  • Durable Medical Equipment
    • Removed procedure codes A4453 and A4459.
  • Temporomandibular Joint (TMJ) Dysfunction
    • Covered diagnosis codes removed from procedure codes 97024, 97110, 97112, 97124, 97140, 97530, 97799, E0720 and E0730.
    • Covered diagnosis codes removed from procedure codes 20605, 50606 and 64400.
  • Drug Testing
    • Annual review for ND.
    • Added the following codes: F10.14, F10.19, F11.23, F11.24, F11.99, F12.23, F13.932, F13.94, F18.890, F18.988, F19.139, F19.20, F19.922, F45.41, G89.3, O99.310, O99.311, O99.312, O99.313, O99.314, O99.315, R44.1, R44.8, R44.9, R45.86, & R45.87 to Procedure codes G0480, G0481,G0482, G0483, G0659, 80305, 80306, 80375, 80376, and 80377 for procedure codes 80307, G0480, G0481, G0482, G0483, G0659, 80305, 80306; 80375 and 80376.
  • Negative Pressure Wound Therapy (NPWT) Pumps/Vacuum Assisted Closure (VAC) of Chronic Wounds
    • Added procedure code 97608.
    • Remove from section "For Stage III and IV Pressure Ulcers:" L89.003, L89.004, L89.103, L89.104, L89.203, L89.204, L89.303, L89.304, L89.503, L89.504, L89.603, L89.604, L89.93 and L89.94.
    • Removed from section "AND one of the following:" I70.239, I70.249, I70.339, I70.349, I70.439, I70.449, I70.539, I70.549, I70.639, I70.649, I70.739, I70.749, L97.101, L97.102, L97.103, L97.104, L97.105, L97.106, L97.108, L97.109, L97.201, L97.202, L97.203, L97.204, L97.205, L97.206, L97.208, L97.209, L97.301, L97.302, L97.303, L97.304, L97.305, L97.306, L97.308, L97.309, L97.401, L97.402, L97.403, L97.404, L97.405, L97.406, L97.408, L97.409, L97.501, L97.502, L97.503, L97.504, L97.505, L97.506, L97.508, L97.509, L97.801, L97.802, L97.803, L97.804, L97.805, L97.806, L97.808, L97.809, L97.901, L97.902, L97.903, L97.904, L97.905, L97.906 and L97.908.
    • Added to section "AND one of the following:" L97.919.
    • Removed from section, "For venous ulcer of lower extremity other than pressure ulcer:" I83.001, I83.002, I83.003, I83.004, I83.005, I83.008, I83.009, I83.201, I83.202, I83.203, I83.204, I83.205, I83.208, and I83.209.
    • Removed from "OR" section: I87.319 and I87.339.
    • Remove, from, section, "Complications, of, a, surgically, created, wound:" T81.4XXA.
    • Add to section, "Complications of a surgically created wound" T81.31XS, T81.32XS, T81.42XA, T81.42XD, T81.42XS, T81.43XA, T81.43XD, T81.43XS, T81.44XA, T81.44XD, T81.44XS, T81.49XA, T81.49XD, T81.49XS, T81.89XS, T87.43, T87.44 and T87.81.
    • Removed from section "Open wound of upper or lower limb, complicated" S41.009A, S41.029A, S41.129A, S41.149A, S51.009A, S51.029A, S51.049A,S41.109A, S51.809A, S51.829A, S51.849A, S61.509A, S61.529A, S61.549A, S71.029A, S71.049A, S71.129A, S71.149A, S81.029A, S81.049A, S81.829A, S81.849A, S91.029A, S91.049A, S91.329A and S91.349A.
    • Added to section, "Open wound of upper or lower limb, complicated" S41.001D, S41.001S, S41.002D, S41.002S, S41.021D, S41.021S, S41.022D, S41.022S, S41.041D, S41.041D, S41.042D,S41.042S, S41.049S, S41.101D, S41.101S, S41.101D, S41.101S, S41.102D, S41.102S, S41.122D, S41.122S, S41.141D, S41.141S, S41.142D, S41.142S, S51.001D, S51.001S, S51.002D, S51.002S, S51.022D, S51.022S, S51.041D, S51.041S, S51.042D, S51.042S, S51.801D, S51.801S, S51.802D, S51.822D, S51.822S, S51.841D, S51.841S, S51.842D, S51.842S, S61.501D, S61.501D, S61.502D, S61.521S, S61.522D, S61.522S, S61.541D, S61.541S, S61.542D, S61.542S,, S71.021D, S71.021S, S71.022D, S71.041S, S71.042D, S71.042S, S71.101A, S71.101D, S71.101S, S71.102A, S71.102D, S71.102S, S71.121D, S71.122S, S71.141D, S71.141S, S71.142D, S71.142S, S81.021D, S81.021S, S81.022D, S81.022S, S81.001A, S81.801A, S81.801D, S81.801S, S81.821D, S81.821S, S81.822D, S81.822S, S81.841D, S81.841S, S81.842D, S91.021S, S91.022D, S91.022S, S91.041D, S91.041S, S91.042D, S91.042S, S91.102A, S91.102D, S91.102S, S91.301S, S91.321D, S91.321S, S91.322D, S91.322S, S91.341D, S91.341S, S91.342D, S91.342S and S51.802S.
  • Spinal Cord and Dorsal Root Ganglion Stimulation
    • Added procedure code C1826.
    • Removed diagnosis codes G90.51, G90.519, G90.52, G90.529, M25.51, M25.519, M25.52, M25.529, M25.53, M25.539, M25.54, M25.549, M25.55, M25.559, M25.56, M25.569, M25.57, M25.579, M79.56, M79.629, M79.63, M79.639, M79.64, M79.643, M79.646, M79.65, M79.659, N79.66, M79.669, M79.67, M79.673, M79676 and R52.
  • Photodynamic Therapy (PDT) with Porfimer Sodium
    • Added diagnosis code C24.0 and removed diagnosis codes C34.10, C34.30, C34.80, C34.90, C78.00 and D02.20.
  • Experimental/Investigational Services
    • Removed procedure code 0202T.
  • External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
    • Removed procedure code 69718.
  • Knee Orthosis
    • Removed duplicates and corrected inadvertently switched diagnosis codes for L1830, L1834, L1851 and L1852.
  • Ankle-Foot/Knee-Ankle-Foot Orthosis
    • Added procedure code L2232.
  • Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography
    • Added diagnosis codes G29.A1, G20.A2, G20.B1, B20.B2 and G20.C.
    • Multiple diagnosis codes removed.
  • Dynamic Splinting
    • Removed multiple diagnosis codes.