• August 3, 2023

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 July 26, 2023. To review our medical policy changes, visit our BCBSND website under medical policies. 

The following medical policies are new:

  • Intense Pulsed Light Therapy for the Treatment of Dry Eye Disease
    • Eyelid thermal pulsation therapy to treat dry eye syndrome is considered not medically necessary.
    • Devices using heat and intermittent pressure for the treatment of evacuating meibomian glands is considered not medically necessary.
    • 0207T, 0563T, 0330T, 0507T: No longer E/I and removed from the Experimental/Investigational Services Policy. Will be considered not medically necessary

 The following medical policies were revised: 

  • Orthopedic Applications of Stem-Cell Therapy 
    • Added statement: Mesenchymal stem cells (MSCs) may also be referred to as bone marrow aspirate or adipose derived stem cells. 
  • Treatment of Abnormal Uterine Bleeding and Uterine Fibroids 
    • Added the following to the symptom list: Transcatheter uterine artery embolization (UAE) of uterine arteries may be considered medically necessary for the treatment of uterine fibroids:
      • Postpartum uterine hemorrhage
      • Placenta accreta, placenta increta or placenta percreta 
  • Urological Supplies 
    • Grammatical revisions 
  • Prophylactic Mastectomy 
    • Additional risk factors added
      • CDH1, STK11 gene mutations or another gene variant associated with high risk
  • Intensity-Modulated Radiotherapy of the Breast & Lung 
    • Updated NCCN guidelines for partial-breast irradiation
      • IMRT of the breast is considered medically necessary as a technique of partial-breast irradiation following breast conserving surgery when medical necessity criteria is met.
  • Transcatheter Pulmonary Valve Implantation 
    • Updated medically necessary criteria section.
      • No change to medical necessity criteria
  • Orthotic & Prosthetic Devices 
    • Grammatical updates to criteria 
  • Devices Used for the Treatment of Obstructive Sleep Apnea in Adults 
    • Grammatical updates made 
  • Hospice 
    • Removed statement due to updated precertification list effective January 1, 2023 
  • Cosmetic Surgery vs. Reconstructive Surgery 
    • Note added: Dermal (medium and deep) chemical peels (treatment) is allowed up to 4 times in a 12-month period if member has meet above criteria. Superficial treatment is allowed up to 6 times per year in a 12-month period if member has meet above criteria. 
  • External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing 
    • Grammatical updates made 
  • Treatment of Benign or Premalignant Skin Conditions 
    • Note added: Dermal (medium and deep) chemical peels is allowed up to 4 times in a 12-month period if member has meet above criteria. 
  • Hospice (Medicaid Expansion) 
    • Removed statement due to updated precertification list effective January 1, 2023. 
  • Nerve Ablation and Injection 
    • Criteria change from: “The use of genicular nerve radiofrequency ablation is considered not medically necessary”
    • Criteria will be: “Intraoperative genicular nerve blocks may be considered medically necessary when used for post-operative pain management.
    • The use of genicular nerve blocks outside the intraoperative period are considered not medically necessary.”

     The following medical policies are consent policies: 

  • Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (LINX®) 
  • Chronic Wound Management 
  • Endoscopic Stricturotomy 
  • Treatment of Hyperhidrosis 
  • Tumor Markers 
  • Confocal Laser Endomicroscopy 
  • Electroretinography 
  • Aqueous Shunts and Stents for Glaucoma 
  • Ultrafiltration in Decompensated Heart Failure 
  • Percutaneous Left Atrial Appendage Closure Devices 
  • Cardiac Applications of Positron Emission Tomography Scanning 
  • Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions and Soft Tissue Wounds 
  • Nebulizers 
  • Home Dialysis Equipment and Supplies 
  • Hyperbaric Oxygen Therapy 
  • Bulking Agents for the Treatment of Urinary Stress Incontinence & Vesicoureteral Reflux 
  • WATS3D Biopsy (e.g., EndoDx) 
  • Nucleoplasty and Biacuplasty 
  • Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease 
  • High Resolution Anoscopy (HRA) 
  • Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover 
  • Discectomy 
  • Arthrocentesis or Needling of Bursa 
  • Pain Management by Injection 
  • Phototherapy for Psychiatric Disorders 
  • Automated External Defibrillators for Home Use 

     The following medical policies had coding changes:  

  • Fecal Microbiota Transplantation 
    • New Code Effective July 1, 2023: J1440 
  • Orthopedic Applications of Stem-Cell Therapy 
    • Removed 3 codes: 20932, 20933, 20934 
    • Adding 2 new codes: A4694, L8699 
  • Intensity-Modulated Radiotherapy of the Breast & Lung 
    • Removed diagnosis code section of policy 
    • Grammatical updates to criteria 
    • Dx codes S83.005A, S83.015A, S83.411A, S83.512A were added 
  • Hepatobiliary System Imaging 
    • Dx codes R10.11 & R10.13 were added and effective July 10, 2023 
  • Amniotic Membrane & Amniotic Fluid 
    • New codes effective July 1, 2023: Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4280, Q4281, Q4282, Q4283, Q4284 
  • Bariatric Surgery 
    • Added July new codes C9784 & C9785 
  • Oncologic Applications of Positron Emission Tomography Scanning 
    • Removed procedure code A-9607 
  • External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing 
    • Removal procedure codes: V5299, 61520, 61530, 61598, L8699, 69714, 69715, 69729, & 69730.
    • Addition of procedure codes: 69710, 69711, 69716, 69717, 69718, 69719, 69726, 69728, 69729, 69730, L8618, L8624. L8628, L8691, & L8694. 
    • Added and removed multiple diagnosis codes.
  • Electroretinography 
    • Removal of 1 diagnosis code H35.311
  • Biomarkers in Risk Assessment and Management of Cardiovascular Disease 
    • Updated diagnosis codes 

The following medical policies will be archived / retiring

  • Medication Assisted Treatment (MAT) 

Note: As a reminder, these policy changes are noted in the ND Committee Review section at the end of the medical policy.

Questions?
If you have additional questions regarding the medical policy changes, contact the appropriate Provider Service Center.

  • BCBSND 1-800-368-2312
  • Medicaid Expansion 1-833-777-5779