Medical Policies 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 our Internal Medical Policy Committee on May 13, 2025. To review our medical policy changes, visit our BCBSND website under Medical Policy Search | BCBSND. 

The following medical policies are new:

  • Decompression and Discectomy, Thoracic
  • Corpectomy, Vertebral
  • Vitamin D Testing

The following medical policies were revised:

  • Speech Generating Devices
    • Changed Eye-gaze technology section from paragraph form to bullets.
  • Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
    • Added verbiage for intraoperative neurophysiological monitoring for in the operating room and outside of the operating room
    • Removed statement: IONM, includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography (EMG) of cranial nerves, electroencephalogram (EEG), and electrocorticography (ECoG), may be considered medically necessary
  • Removed thyrotoxicosis and thyroiditis bullets
    • Added section: Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves are considered not medically necessary.
  • Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERDX)
    • Description revised
    • Added GERDX
    • Added LINX section (policy S-233 [Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (LINX®)] archived, moved here)
  • Foot Orthotics for Conditions Other Than Diabetes
    • Reworded description and policy criteria
  • Wheelchairs (WC) and Options/Accessories
    • Made section titles more distinct
  • Cardiac Ablation Procedures
    • Changed the word ‘any’ to ‘ONE or more’
    • Removed ‘or’
    • Added ‘or Pulsed Field Ablation (PFA)’ to Transcatheter Radiofrequency Ablation, Cryoablation section
    • In Maze section reworded statement
    • In HyCASA section was removed difficult to treat drug resistant
    • Updated Professional Statement
  • Fecal Microbiota Transplantation (FMT)
    • Added 'ALL of' in the FMT section
  • Hematopoietic Cell Transplantation: Experimental/Investigational Services
    • Removed bullet (sarcoma, soft tissue)
  • Laser Interstitial Thermal Therapy
    • Verbiage update in description
    • Professional statement updated
  • Hip Resurfacing
    • Updated policy description
    • Devices Used for the Treatment of Obstructive Sleep Apnea in Adults
    • Updated statement: 'A trial with continuous positive airway pressure (CPAP) has failed or is contraindicated' to 'A trial with CPAP has failed, or is contraindicated, or the individual prefers alternate therapy; and'
    • Removed statement: Intra-oral devices do not meet the above criteria if there is a signed affidavit refusing CPAP treatment and therefore considered not medically necessary.
  • Nebulizers
    • Added 'or' to the end of bullet statements
  • Electric Breast Pump
    • Added Convenience item section (A4287)
  • Sclerotherapy (Liquid or Micro foam)

Added: Sclerotherapy may be considered medically necessary for the treatment of the great saphenous veins, small saphenous veins, or saphenous tributaries, including accessory saphenous veins

The following medical policies are consent policies:

  • Clinical Trials
  • Rapid Platelet Function Assay - ASA
  • Seat Lift Mechanisms
  • Trans Anal Irrigation
  • Home Cervical Traction Therapy
  • Acellular Dermal Matrix Grafts (formerly Arthrex Bovine Collagen)
  • Intra-Arterial/Intravenous Therapeutic Procedures
  • Hematopoietic Cell Transplantation: Solid Tumors
  • Cardiac Contractility Modulation Therapy
  • Spider Veins, Treatment
  • Respiratory Assist Devices
  • Pulmonary Rehabilitation
  • Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
  • Speech Therapy

Osseointegrated Dental Implants

The following medical policies had coding changes:

  • Wheelchairs (WC) and Options/Accessories
    • Added April new procedure codes E1022, E1023, E1032, E1033, and E1034
  • Diagnosis and Treatment of Male Sexual Dysfunction
    • Added April new procedure code E0201 and removed deleted procedure code S4988
  • Braces and Supports
    • Added April new procedure code L0720
  • Dynamic Splinting Devices
    • Added April new procedure code E1832
  • Ankle-Foot/Knee-Ankle-Foot Orthosis
    • Added April new procedure codes L1933 and L1952
  • Myoelectric Prosthetic Components for the Upper Limb
    • Added April new procedure codes L6031, L6700, and L7406
    • Removed L6975
  • Lower Limb Prostheses
    • Added April new procedure code L5827
  • Bioengineered Skin
    • Added April new procedure codes A2030, A2031, A2032, A2033, and A2034
  • Mastectomy and Reconstructive Surgery
    • Added April new procedure code L8010
  • Amniotic Membrane and Amniotic Fluid
    • Added April new procedure codes A2035, Q4355, Q4356, Q4357, Q4358, Q4359, Q4363, Q4364, Q4365, Q4366, and Q4367
    • Removed deleted code Q4231
  • Assisted Reproductive Technology
    • Added April new procedure code S4024
  • Cardiac Applications of Positron Emission Tomography Scanning
    • Added April new procedure code S4024
  • Experimental/Investigational
    • Added April new procedure codes C8004, 0542U, 0543U, 0554U, 0547U, 0548U, 0550U, and 0551U
  • Biomarkers in Risk Assessment and Management of Cardiovascular Disease
    • Added April new procedure code 0541U
  • Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
    • Removed procedure codes 95907, 95908, 95910, 95911, 95912, 95913, and 95937
    • Added procedure codes 95961, 959632, 95822, 95866, 95870, 95865, and 95930
    • Added diagnosis code C41.0 and D34.5
    • Removed diagnosis codes E05.00, E05.01, E05.10, E05.11, E05.20, E05.21, E05.30, E05.31, E05.40, E05.41, E05.80, E05.81, E05.90, E05.91, E07.9, E21.0, E21.1, E21.2, E21.3, E21.4, E21.5,
    • 3, G24.4, G25.1, G25.2, G25.5, G25.71, G25.79, G25.89, G25.9, G26, G40.111, G40.842, G40.843, G40.844, G40.301, G40.309, G40.401, G40.409, G40.501, G40.509, G40.89, G45.1, G45.2, G45.8, G45.9, G46.0, G46.1, G46.2, G46.3, G46.4, G50.0, G50.1, G80.3, G80.4, G80.8, G80.9, G96.44, G93.5
    • 01, H71.02, H71.03, H71.11, H71.12, H71.13, H71.21, H71.22, H71.23, H71.31, H71.32, H71.33, H71.91, H71.92, H71.93
    • 8, I46.9, I63.011, I63.012, I63.013, I63.02, I63.031, I63.032, I63.033, I63.09, I63.111, I63.112, I63.113, I63.12, I63.131, I63.132, I63.133, I63.19, I63.20, I63.211, I63.212, I63.213, I63.22, I63.231, I63.232, I63.233, I63.29, I63.311, I63.312, I63.313, I63.319, I63.321, I63.322, I63.323, I63.331, I63.332, I63.333, I63.341, I63.342, I63.343, I63.39, I63.411, I63.412, I63.413, I63.421, I63.422, I63.423, I63.431, I63.432, I63.433, I63.441, I63.442, I63.443, I63.49, I63.511, I63.512, I63.513, I63.521, I63.522, I63.523, I63.531, I63.532, I63.533, I63.541, I63.542, I63.543, I63.59, I63.6, I63.81, I63.89, I63.9, I67.2, I67.5
    • 751, M21.752, M21.761, M21.762, M21.763, M21.764, M40.202, M40.203, M40.204, M40.205, M40.292, M40.293, M40.294, M40.295, M40.35, M40.36, M40.37, M40.45, M40.46, M40.47, M40.55, M40.56, M40.57, and Z98.890
    • Moved 0464T from maybe medically necessary section to experimental/investigational section.
  • Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
    • Added procedure codes 43284, 43285, and 43289 (LINX) section as medically necessary
    • Added diagnosis codes K21.00, K21.01, and K21.9 to procedure code 43284
  • Wheelchairs (WC) and Options/Accessories
    • Added procedure codes E1011, E1227, E1228, E2227, E2628, E2630, E2632, and E2633
  • Cardiac Ablation Procedures
    • Removed procedure code 93656 from the ‘Catheter Ablation Procedure’ Section of the policy
    • Added diagnosis codes I48.92 and I49.5 for procedure code 93650
    • Added diagnosis codes I49.01 and I49.02 for procedure code 93654
    • Added diagnosis code I47.9 for procedure code 93655
    • Added diagnosis codes I25.5, I25.6, I25.9, I25.89, I42.0, I42.2, I42.5, I42.8, I42.9, I44.0, I44.1, I44.2, I44.30, I45.6, I45.81, I45.859, I47.0, I47.9, I47.10, I47.11, I47.19, I47.20, I47.89, I48.0, I48.3, I48.4, I48.91, I48.92, I59.5, I49.8, I49.40, and R00.1
    • Removed diagnosis code I48.8 from procedure codes 33254, 33255, 33256, 33257, 33258, and 33259
  • Heart Transplant
    • Removed diagnosis code I47.1
  • Leadless Cardiac Pacemakers
    • Removed Diagnosis Code: I47.2
    • Added Diagnosis Codes: I47.20, I47.21, and I47.29
  • Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
    • Removed diagnosis code M48.06 as needs more digits.
  • Experimental/Investigational
    • Removed procedure codes 0479T, 0480T, A4544 and E0743
    • Added procedure code C8004
    • Removed duplicate procedure code
  • Ilizarov Bone Lengthening
    • Removed diagnosis codes: M21.029, M21.059, M21.069, M21.129, M21.159, M21.169, M21.729, M21.739, M21.759, M21.769, M21.829, M21.839, M21.859, M21.929, M21.939, M21.959, M21.969, M80.019K, M80.019P, M80.029K, M80.029P, M80.039K, M80.039P, M80.049K, M80.049P, M80.059K, M80.059P, M80.069K, M80.069P, M80.079K, M80.079P, M80.829K, M80.829P, M80.839K, M80.839P, M80.869K, M80.869P, M80.879K, M80.879P
    • 20, Q71.40, Q71.50, Q71.819, Q71.899, Q71.90, Q72.20, Q72.40, Q72.50, Q72.60, Q72.70, Q72.819, Q72.899, Q72.90, and Q73.8
  • Home Pulse Oximetry Device
    • Removed diagnosis code P28.3 due to missing digits
    • Add diagnosis codes P28.30, P28.31, P28.32, P28.33, and P28.39
  • Electric Breast Pump
    • Added procedure code A4287
  • Sclerotherapy (Liquid or Micro foam)
    • Removed dx codes: I83.201, I83.202, I83.203, I83.204, I83.205, I83.208, I83.209, I83.819, I83.899, and I87.9 (unspecified side)

The following medical policies will be archived / retiring:

  • Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (LINX®)
  • Transcutaneous Transducer Garments
  • Vitamin D Assay