Medical Policies Available September 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 July 22, 2021, and will be updated within the next 30-45 days on our website. To review our medical policy visit our BCBSND website under medical policies.

The following medical policies are new:

  • Implantable Cardioverter Defibrillator
  • Phototherapy for Psychiatric Disorders
  • Automated External Defibrillators for Home Use
  • Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors

The following medical policies were revised:

  • Transcatheter Mitral Valve Repair/Replacement
    • Revised a not medically necessary statement to experimental/ investigational
  • Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
    • Minor verbiage change such as: not meeting the criteria as indicated in this policy
  • Percutaneous Left Atrial Appendage Closure Devices
    • Language change from patients to individuals
  • Knee Orthosis
    • Revised the tables within the policy
  • External Counterpulsation (ECP)
    • Expanded some bullet points
  • Hydrogel Spacer use During Radiotherapy for Prostate Cancer
    • Expanded how an experimental/investigational statement was written
  • Tumor Treatment Fields
    • NovoTAL Treatment Planning Software:
      • NovoTAL is considered EXPERIMENTAL / INVESTIGATIVE due to a lack of clinical evidence demonstrating an impact on improved health outcomes.
  • Pulmonary Rehabilitation (HMK is Outpatient Pulmonary Rehabilitation)
    • Comprehensive outpatient PR programs may include: team assessment, individual training, psychosocial intervention, exercise training, and follow-up.  PR program length may be considered medically necessary for up to 18 sessions, depending on program and may include the following:
  • Telehealth
    • See policy, multiple revisions within policy
  • Hematopoietic Cell Transplant for Hodgkin Lymphoma 
    • Expanded and made the medically necessary indications more detailed
  • Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
    • Expanded and made the medically necessary indications more detailed

The following medical policies are consent policies:

  • Arthrex Bovine Collagen
  • Radiofrequency Ablation of Peripheral Nerves to Treat Chronic Knee Pain
  • OralCDx Brush Biopsy
  • Diabetic Services and Supplies
  • Nucleoplasty and Biacuplasty
  • Cardiac Applications of Positron Emission Tomography Scanning
  • Gastric Electrical Stimulation, Gastric Pacing
  • Posterior Tibial Nerve Stimulation
  • Electrical Stimulation Devices for the Treatment of Arthritis
  • Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease
  • Removal of Benign or Premalignant Skin Lesions
  • High Resolution Anoscopy (HRA)
  • Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover
  • Discectomy

The following medical policies had coding changes:

  • Cardiac Monitors
  • Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
  • Experimental-Investigational
  • Tumor Markers
  • Braces and Supports
  • Hematopoietic Cell Transplantation for Solid Tumors of Childhood
  • Drug Testing
  • Mohs Micrographic Surgery (MMS)
  • Nerve Fiber Density Testing
  • WATS3D Biopsy(EndoCDx)
  • Wearable Cardioverter-Defibrillator