Medical Policies Available Online

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 January 20, 2022. To review our medical policy changes, visit bcbsnd.com under medical policies.

The following medical policies are new:

• Not applicable this month.

The following medical policies were revised:

• Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents
  • Revised how the experimental/investigational statement is worded
• Wheelchairs (WC) and Options/Accessories
  • Minimal verbiage changes – changing how “not medically necessary” statements were written
• Transcatheter Closure Devices for Septal Defects
  • Revision to the experimental/investigational statement
  • Added a table in the operational guidelines / professional statements
• Treatment of Malignant Skin Lesions
  • Title change; was “Mohs Micrographic Surgery (MMS)”
  • Added the information from policy S-71 to this policy
• Treatment of Benign or Premalignant Skin Conditions
  • Title change; was “Removal of Benign or Premalignant Skin Lesions”
  • Added the information from policy G-40 to this policy
• Fecal Microbiota Transplantation
  • Adding one bullet to the medical criteria
  • Revision to the experimental/investigational statement
• Per-Oral Endoscopic Myotomy (POEM)
  • Adding age to criteria
• Hematopoietic Cell Transplantation for Treatment of Germ-Cell Tumors
  • Revised description statement
• Islet Cell Transplantation
  • Revision of one word within statement
• Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
  • Revised the professional statements
• Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
  • Updated description
  • Updated professional statements
• Telehealth
  • Place of service 10
• Ablation of Miscellaneous Solid Tumors
  • Title change; was “Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors”
  • Added policy criteria from policy S-158 into this policy
• Drug Testing
  • Revision of how policy is formatted
• Treatment of Abnormal Uterine Bleeding and Uterine Fibroids
  • Title change; was “Treatment of Abnormal Uterine Bleeding and Fibroids”
• Chronic Wound Management
  • Removed sentence: “Electrical stimulation is considered not medically necessary as an initial treatment modality.”
  • Changed “not covered” to “not medically necessary”
• Bariatric Surgery
  • Added “not medically necessary” statements
  • Revised how the criteria was laid out

The following medical policies are consent policies:

• Ultraviolet Light Therapies
• Acupuncture for Pain Management, Nausea and Vomiting and Opioid Dependence
• Cleft Palate/Lip Reconstruction
• Ambulance Services: Air and Water Transportation
• Ambulance Services: Ground Transportation
• Cochlear Implantation
• Medication Assisted Treatment (MAT)
• Eustachian Tube Balloon Dilation
• CT (Virtual) colonoscopy
• Artificial Intervertebral Disc Replacement
• Temporomandibular Joint (TMJ) Dysfunction
• Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
• Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
• In Vitro Allergy Testing
• Vitamin D Assay
• Intra-Arterial/Intravenous Therapeutic Procedures
• Foot Care Services
• Pancreas Transplant
• Kidney Transplant
• Electroretinography
• Dry Needling of Myofascial Trigger Points
• Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
• Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
• Surgical Treatment of Femoroacetabular Impingement
• Radioembolization for Primary and Metastatic Tumors of the Liver

The following medical policies had coding changes:

Please note this is not an all-encompassing list. Some policies with new codes for January 1, 2022 were addressed in the November 2021 HCN. CMS continues to send updates.

• Endobronchial Valve Surgery
  • Added Dx codes
• Telehealth
  • Removed 99211
• Ablation of Miscellaneous Solid Tumors
  • Title change; was “Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors”
  • Added procedure codes from policy S-158 into this policy
• Drug Testing
  • Removed 0006U (it is a deleted code)
• WATS3D Biopsy (EndoCDx)
  • Removed code 99000
• Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non–Orthopedic Conditions
  • Added G0465 as a new code for January 1, 2022
• Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)
  • Added 61736 and 61737 as new codes
• Coronary Revascularization
  • Removed codes effective January 1, 2022: 93530, 93531, 93532, 93533
  • Added new codes effective January 1, 2022: 93593, 93594, 93595, 93596, 93597, 93598
• Lumbar Spinal Fusion
  • Added two new codes: 63052 and 63053 effective January 1,2022
  • Also added C1831
• Implantable Cardioverter Defibrillators
  • Added codes: 0674T, 0675T, 0676T,0677T, 0678T, 0679T, 0680T, 0681T, 0682T, 0683T, 0684T, 0685T
• Bone Mineral Density Studies
  • Effective January 1, 2022, added new codes: 77089, 77090, 77091, 77092
  • Also added codes: 0508T, 0554T, 0555T, 0556T, 0557T, 0558T
• Bariatric Surgery
  • Added codes 43659 and 44238
• Allergy Skin Testing
  • Removed code 86343
• Measurement of Exhaled Nitric Oxide
  • Updated Dx codes for 95012, covered Dx codes
• Experimental/Investigational Services
  • For January 1, 2022, removed and added multiple codes. Please see bottom of policy for specifics.

The following medical policies are being archived:

• Bronchial Thermoplasty
• Dermatological Applications of Photodynamic Therapy
  • This policy information is now a part of S-46.
• Actinic Keratosis
  • This policy information is now a part of S-36.
• Cryosurgical Ablation and Radiofrequency Ablation of Renal Tumors
  • This policy is being archived and combined with S-137.