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 May 23, 2023. To review our medical policy changes, visit our BCBSND website under medical policies.
The following medical policies are new:
- Surgical Treatments for Breast Cancer-Related Lymphedema
- Surgical Treatment of Obstructive Sleep Apnea
- Composite Tissue Allotransplantation of the Hand
The following medical policies were revised:
- Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
- Added additional medically necessary criteria bullets
- Removed the surgical sections as they will be part of a new policy in S-280
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- Removed the surgical sections as they will be part of a new policy in S-280
- Fecal Microbiota Transplantation
- Changed Criteria from Vancomycin specific to "any antibiotic"
- From three recurrences to two
- Added criteria for: Rebyota (fecal microbiota, live jslm) is a single-dose microbiota-based live biotherapeutic that may be indicated for the prevention of recurrent CDI.
- Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
- IONM performed for more than one procedure at a time is considered not medically necessary
- Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
- Updating E/I statement to indicate not medically necessary.
- Adding criteria for Surgical fundoplication for the treatment of GERD
- Devices Used for Treatment of Obstructive Sleep Apnea in Adults
- Adding: Sleep positioning trainer with vibration is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-review literature.
- Transcutaneous Transducer Garments
- Adding criteria for: Functional neuromuscular electrical stimulation (NMES)
- Cosmetic vs. Reconstructive Surgery
- Revision update statement: the following procedures may be medically necessary upon review of the member’s applicable benefit coverage. Coverage is subject to the specific terms of the member’s benefit plan.
- Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
- Add summary of evidence
- Policy updated with literature review
- References added
- Ambulatory Blood Pressure Monitoring
- Added section of criteria for suspected masked hypertension.
The following medical policies are consent policies:
- Cranial Orthosis for Plagiocephaly
- Esophageal pH Monitoring
- Physical Therapy
- Lower Limb Prostheses
- Foot Orthotics for Conditions Other Than Diabetes
- Hematopoietic Cell Transplantation: Non-Cancer Diseases
- Hematopoietic Cell Transplantation: Blood Cancers
- Hematopoietic Cell Transplantation: Experimental/Investigational Services
- Kidney Transplant
- Gastric Electrical Stimulation, Gastric Pacing
- Diagnosis and Treatment of Male Sexual Dysfunction
- Negative Pressure Wound Therapy (NPWT) Pumps/Vacuum Assisted Closure (VAC) of Chronic
- Non-Powered Negative Pressure Wound Therapy System
- Photodynamic Therapy (PDT) with Porfimer Sodium
- Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease
- Biomarkers in Risk Assessment and Management of Cardiovascular Disease
- Home Health – Extended Hours
- Cerebral Oxygenation Monitoring using Near Infrared Spectroscopy (NIRS)
- Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
- Posterior Tibial Nerve Stimulation
- Nerve Ablation and Injection
- Manipulation Under Anesthesia
- Acellular Dermal Matrix Grafts
- Cervical Fusions
- Hospice
- Surgical Treatment of Varicose Veins
- Ilizarov Bone Lengthening
- Pap Smears with Medical Conditions
- Discography
- Orthopedic Applications of Platelet-Rich Plasma
- Ocular Photodynamic Therapy (PDT)
- Leadless Cardiac Pacemaker
- Home Pulse Oximetry Device
- Proton Beam Radiation Therapy - FM Homebuilder’s Consortium and Eide Bailly only
- Feeding Disorder Program
The following medical policies had coding changes:
- Allergy Immunotherapy
- Adding 95199 back into policy
- Experimental-Investigational
- update codes that were deemed not FDA approved by CMS: ADD: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A, 90666, 90667, 90668, 91300, 91301, 91305 , 91306, 91307, 91308, 91309, 91311, Q0220, Q0221, Q0222, Q0240, Q0243, Q0244, Q0245, Q00247
- Removed: 0470T, 0471T, 0707T, K1001
- Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
- removing codes that will be in new policy S-280
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- removing codes that will be in new policy S-280
- Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
- Adding 95941 back into the policy
- Ultrasound Osteogenesis Stimulator
- Update to Dx codes
- Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
- Update to Dx codes
- Devices Used for Treatment of Obstructive Sleep Apnea in Adults
- Adding code K1001, A7031, A7032
- Transcutaneous Transducer Garments
- Adding E0745
- Mastectomy and Reconstructive Surgery
- Adding codes 15771 and 15772
- Cosmetic vs. Reconstructive Surgery
- Adding codes 15771, 15772, 15773, 1577
Questions?
Contact our Commercial Provider Service Center at 1-800-368-2312 or Medicaid Expansion Provider Service Center at 1-833-777-5779 for additional information.
