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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 March 16, 2020. Please see policy for changes. Medical policies are available at www.bcbsnd.com/web/providers/policies.

The following new and revised medical policies are effective May 1, 2020:

See additional article below regarding Pharmacy Updates:

  • Breast Ductal Lavage and Fiberoptic Ductoscopy
  • Rapid Platelet Function Assay
  • Patient Lifts
  • Transcutaneous Transducer Garments
  • Ultra-Rapid Opiate Detoxification
  • Myocardial Strain Imaging
  • Photon Beam Therapy
  • Nerve Fiber Density Testing
  • Laminectomy
  • Frenectomy or Frenotomy or Ankyloglossia
  • Digital Imaging Systems for the Detection and Evaluation of Diabetic Retinopathy
  • Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and Colon
  • Sacral Nerve Neuromodulation/Stimulation
  • Manipulation Services
  • Obesity
  • Transcatheter Aortic Valve Replacement
  • Cosmetic and Reconstructive

Pharmacy Policies Available Online

The following medical drug policies are new and require precertification:

  • Blinatumomab (Blincyto)
  • Enfortumab vedotin-ejfv (Padcev)
  • Fam-trastuzumab Deruxtecan-nxki (Enhertu)
  • Givosiran (Givlaari)
  • Luspatercept (Reblozyl)
  • Teprotumumab-trbw (Tepezza)

The following medical drug policies were revised and require precertification:

  • Chemodenervation with Botulinum Toxin
  • Elotuzumab (Empliciti)

The following medical drug policies were revised:

  • Alemtuzumab (Lemtrada™)
  • Alglucosidase alfa (Lumizyme)
  • Crizanlizumab-tmca (Adakveo)
  • Drug Indications
  • Eculizumab (Soliris) and Ravulizumab (Ultomiris)
  • Golimumab (Simponi Aria)
  • Granulocyte Colony-Stimulating Factors
  • Infliximab
  • Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
  • Natalizumab (Tysabri)
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)
  • Portable External Infusion Pump
  • Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela)
  • Therapeutic Radiopharmaceuticals in Oncology
  • Tocilizumab (Actemra)
  • Ustekinumab (Stelara)
  • Vedolizumab (Entyvio®)

The following new Utilization Management (UM) programs on the pharmacy benefit went into effect on April 1, 2020:

  • Baclofen PAQL
  • Nasal Antiepileptics QL
  • Procysbi PA
  • Wakix PAQL