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 the Internal Medical Policy Committee on Nov. 6, 2025. To review our medical policy changes, visit our BCBSND website under medical policies.

The following policies will take effect on Jan. 1, 2026.

The following medical policies are new:

  • Aqueous Shunts and Stents for Glaucoma
  • Computerized Corneal Topography
  • Renal Denervation System
  • Skin Substitutes
  • Supplementary Algorithm for Cardiac Magnetic Resonance Imaging
  • Fibrin Sealant

The following medical policies were revised:

  • Patient Lifts
    • Criteria updated
  • Biofeedback
    • Updated age requirements and clarified language
  • Miscellaneous Services
    • Added definition for breast computed tomography (CT)
  • Intensity-Modulated Radiotherapy of the Breast and Lung
    • Updated description and Literature review
    • Added policy guideline table
  • Oncologic Applications of Positron Emission Tomography Scanning
    • Updated policy criteria, literature, tables, and references
  • Basivertebral Nerve Ablation
    • Updated professional statement
  • Ligation or Laser Ablation, Incompetent Perforator Veins
    • Added 'Laser' to the policy title
  • Eustachian Tube Balloon Dilation
    • Added pediatric criteria for ages 8-17 years old
  • Endobronchial Valve Surgery
    • Updated language
  • Transcatheter Closure Devices for Septal Defects
    • Updated language
  • Decompression and Discectomy, Thoracic
    • Updated language: removed initial criteria outlined above have been met to initial procedure was approved
  • Electroretinography
    • Updated language: changed 'any one' to 'one or more'
  • Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
    • Updated language
    • Added policy guidelines and
    • Updated references
  • Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest
    • Updated language
    • Added policy guidelines
    • Updated references
  • Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
    • Updated description and literature review
  • Intensity-Modulated Radiotherapy of the Prostate
    • Added policy guidelines and updated description
  • Intensity-Modulated Radiotherapy: Central Nervous System Tumors
    • Added policy guidelines and updated literature
  • Tumor Markers
    • Updated language
  • Cochlear Implantation
    • Added replacement verbiage
    • Updated professional statements
  • Wearable Cardioverter-Defibrillator
    • Updated language
  • Temporomandibular Joint (TMJ) Dysfunction
    • Added lifetime benefit of surgical maximum
  • Ablation of Miscellaneous Solid Tumors
    • Criteria updated throughout policy
    • Added criteria for Thyroid cancer
  • Electrical Nerve Stimulation
    • Criteria for ReActiv8 changed from E/I to medically necessary with criteria.
  • Pneumatic Compression Devices
    • Changed chest and trunk to medically necessary
    • Changed non-segmented to single compartment and segmented to multichambered
  • Cosmetic Surgery vs. Reconstructive Surgery
    • Updated criteria titles
  • Axial Lumbosacral Interbody Fusion
    • Updated literature

The following medical policies are consent policies:

  • Discography
  • Ultra-Rapid Opiate Detoxification (UROD)
  • Digital Imaging Systems for the Detection and Evaluation of Diabetic Retinopathy
  • Small Bowel, Small Bowel/Liver and Multivisceral Transplant
  • Acellular Dermal Matrix Grafts
  • Chronic Pain Programs
  • Islet Cell Transplantation
  • Ablation of Liver Tumors
  • Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
  • Frenectomy or Frenotomy for Ankyloglossia
  • Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease
  • Implantable Pulmonary Artery Pressure Measurement Device
  • Mobile Cardiac Outpatient Telemetry (MCOT)
  • Rabies Vaccination and Immune Globulin
  • Orthopedic Applications of Platelet-Rich Plasma
  • Lymphoscintigraphy
  • Peer Support
  • Intracellular Micronutrient Testing Panel
  • Gender Affirmation Treatment
  • Cardiac Ablation Procedures
  • Bariatric Surgery

The following medical policies had coding changes:

  • Durable Medical Equipment (DME)
    • Added October new code E0150
    • Effective Oct.1, 2025
    • Added diagnosis codes G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, and G35.D
    • Removed diagnosis code G35
  • Electric Breast Pumps
    • Added October new code A9288
    • Effective Oct. 1, 2025
  • Braces and Supports
    • Added October new code L1007
    • Effective Oct. 1, 2025
  • Myoelectric Prosthetic Components for the Upper Limb
    • Added procedure code L6975
  • Oncologic Applications of Positron Emission Tomography Scanning
    • Added October new code A9616
    • Effective Oct. 1, 2025
  • Topic: Non-Powered Negative Pressure Wound Therapy System
    • Removed diagnosis codes: T81.32XA and T81.32XD
    • Add diagnosis codes L98.A111, L98.A112, L98.A113, L98.A114, L98.A119, L98.A121, L98.A122, L98.A123, L98.A124, L98.A129, L98.A211, L98.A212, L98.A213, L98.A214, L98.A215, L98.A218, L98.A219, L98.A221, L98.A222, L98.A223, L98.A224, L98.A225, L98.A228, L98.A229, L98.A311, L98.A312, L98.A313, L98.A314, L98.A319, L98.A321, L98.A322, L98.A323, L98.A324, L98.A325, L98.A326, L98.A328, L98.A329, and L98.A391
  • High Frequency Chest Wall Oscillation Devices
    • Added diagnosis codes: G35.A, G35.B0, G35.B1, G35.B2, G35.C0 G35.C1, G35.C2, and C35.D
    • Removed Diagnosis Code: G35
  • Seat Lift Mechanisms
    • Added diagnosis codes: G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, C35.D, and M05.A
    • Removed Diagnosis Code: G35
  • Chronic Wound Management
    • Added Diagnosis Codes:
      431, L98.433, L98.434, L98.441, L98.444,L98.445, L98.446, L98.448, L98.449, L98.451, L98.454, L98.455, L98.456, L98.458, L98.459,L98.461, L98.463, L98.464, L98.471, L98.472, L98.473, L98.474, L98.475,L98.476, L98.478, L98.479, L98.A111, L98.A112, L98.A113,L98.A118, L98.A119, L98.A121, L98.A122, L98.A123, L98.A124, L98.A125, L98.A126, L98.A128, L98.A129, L98.A193, L98.A194, L98.A195, L98.A196, L98.A198, L98.A199, L98.A211, L98.A212, L98.A213, L98.A214, L98.A215, L98.A216, L98.A218, L98.A221, L98.A222, L98.A224, L98.A225, L98.A226,L98.A228, L98.A229, L98.A291, L98.A293, L98.A294, L98.A295, L98.A296, L98.A298, L98.A299, L98.A311, L98.A312, L98.A313, L98.A314, L98.A315, L98.A316, L98.A318, L98.A322, L98.A323, L98.A391, L98.A392, L98.A395, L98.A396, L98.A398, L98.A399, I70.239, I70.249, I70.339, I70.349, I70.439, I70.449, I70.539, I70.549, I70.639, I70.649, I70.739, and I70.749
    • Removed diagnosis code T81.32XS
  • Electroencephalogram
    • Added G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, C35.C2, and G35.D
    • Removed diagnosis code G35.
  • Chelation Therapy for Off-Label Uses
    • Added G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, C35.C2, C35.D, and M05.A
    • Removed diagnosis code: G35
  • Foot Orthotics for Conditions Other Than Diabetes
    • Added M05.A to diagnosis codes
  • Cranial Electrotherapy Stimulation and Auricular Electrostimulation
    • Added procedure code 0783T
  • Apheresis Therapy
    • Under Covered Diagnosis Codes for 36511
      • Added E78.010, E78.011, E78.019, G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35C2, and G35.D
      • Removed E78.01, and G35
    • Under Covered Diagnosis Codes for 36512, 36513, 36514, 36516
      • Added diagnosis codes E78.010, E78.011, E78.019, G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35C2, and G35.D
      • Removed diagnosis codes E78.01 and G35
    • Under Covered Diagnosis Codes for 36516, S2120
      • Added diagnosis codes E78.010, E78.011, and E78.019
      • Removed diagnosis E78.01
    • Under Covered Diagnosis Codes for 36522
      • Added diagnosis codes G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35C2, and G35.D
      • Removed diagnosis code G35
  • Experimental/Investigational
    • Removed Termed Procedure Codes: K1023, M0240, M0243, M0244, M0245, M0247, Q0220, Q0221, Q0222, Q0240, Q0243, Q0244, Q0245, and Q0247
  • Foot Care Services
    • Under Covered Diagnosis Codes for 11055, 11056, 11057, 11719, 11720, 11721, G0127, G0245, G0246, and S0390
      • Added diagnosis codes G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35C2, and G35.D
      • Removed diagnosis codes G35
  • Pneumatic Compression Devices
    • E0658 and E0659
  • Lower Limb Prostheses
    • L5657
  • Bioengineered Skin and Soft Tissue Substitutes
    • Added A2036, A2037, A2038, and A2039
  • Amniotic Membrane & Amniotic Fluid
    • Added diagnosis codes Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, and Q4397
  • Physical Therapy
    • Under covered Diagnosis Code for S9476
      • Added diagnosis codes G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, and G35.D
      • Removed G35
  • Phototherapy for Psychiatric Disorders
    • Removed procedure code: E0691
  • Category III T Codes
    • Removed procedure codes: 0633T, 0634T, 0635T, 0636T, 0637T, and 0368T-moved to Z-24
    • Removed procedure code: 0783T to E-16
    • Removed procedure codes: 0338T and 0339T moved to S-342
    • Removed codes: 0897T, 0898T, 0899T, and 0900T- moved to M-91
  • Negative Pressure Wound Therapy Pumps/Vacuum Assisted Closure of Chronic Wounds
    • Added L98.A111, L98.A112, L98.A113, L98.A114, L98.A115, L98.A116, L98.A118, L98.A119, L9 A121, L98.A122, L98.A123, L98.A124, L98.A125, L98.A126, L98.A128, L98.A129, L98.A211, L98.A212, L98.A213, L98.A214, L98.A215, L98.A216, L98.A218, L98.A219, L98.A221, L98.A222, L98.A223, L98.A224, L98.A225, L98.A226, L98.A228, L98.A229, L98.A311, L98.A312, L98.A313, L98.A314,L98.A315, L98.A316, L98.A318, L98.A319, L98.A321, L98.A322, L98.A323, L98.A324, L98.A325, L98.A326, L98.A328, and L98.A329
  • Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions
    • Added procedure codes to Covered Diagnosis Codes for Procedure Codes: S0157, S9055 adding L98.432, L98.433, L98.434, L98.435, L98.436, L98.438, L98.439, L98.442, L98.443, L98.444, L98.445, L98.446, L98.448, L98.449, L98.451, L98.452, L98.453, L98.454, L98.455, L98.456, L98.458, L98.462, L98.463, L98.464, L98.465, L98.466, L98.468, and L98.469
  • Percutaneous Tenotomy
    • Removed procedure code 27000
  • Outpatient Pulmonary Rehabilitation
    • Removed procedure codes 97001 and 97002
  • Hematopoietic Cell Transplantation: Non-Cancer Diseases
    • Added diagnosis code D71.1
  • Aqueous Shunts and Stents for Glaucoma
    • Added diagnosis codes: H40.841, H40.842, H40.843, and H40.849, Q40.841, Q40.842, Q40.843, and Q40.849
  • Allergy Skin Testing
    • Added diagnosis codes for procedure codes 95004, 95017, 95018, 95024, 95027, 95028, 95076, and 95079: T78.070A, T78.070D, T78.070S, T78.071A, T78.071D, T78.071S, T78.079A, T78.079D, T78.079S, T78.080A, T78.080D, T78.080S, T78.081A, T78.081D, T78.081S, T78.089A, T78.089D, T78.089S, T78.110A, T78.110D, T78.110S, T78.111A, T78.111D, T78.111S, T78.119A, T78.119D, T78.119S, T78.120A, T78.120D, T78.120S, T78.121A, T78.121D,T78.121S, T78.129A, T78.129D, T78.129S, T78.19XA, T78.19XD, and T78.19XS
    • Removed diagnosis codes T78.07XA, T78.07XD, T78.08XD, T78.08XS, T78.1XXA, T78.1XXD, and T78.1XXS
    • Added diagnosis codes for procedure codes 95076, 95079: T36.9X5A, T36.5X5D, and T36.9X5A
  • Electromagnetic Navigational Bronchoscopy (ENB)
    • Removed procedure codes 31626, A4648, 31627, C1739, and C9751
    • Added procedure code C9728
    • Removed diagnosis codes C34.00, C34.30, C34.80, and C34.90
    • Added diagnosis codes R91.8
    • Changed the verbiage under covered diagnosis: Covered diagnosis codes for procedure code 31627 when reported with 31615, 31622, 31623, 31624, 31625, 31626, 31628, 31629, 31630, 31631, 31635, 31636, 31637, 31638, 31640, 31641, and 31643
  • Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)
    • Added procedure code: C9734 --Code was removed January 2025 as a termed code, but code did not term
  • Diabetic Services, Continuous Glucose Monitoring, and Supplies
  • Drug Testing
    • Added Non-Covered Diagnosis Code F19.922
    • Removed diagnosis code F13.252
    • Updated diagnosis code Z79.81 to Z79.891
  • Wheelchairs and Options/Accessories
    • Added Diagnosis Codes G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, and G35.D
    • Removed Diagnosis Code G35

The following medical policies will be archived / retiring:

  • Cervical Fusions
  • Corneal Topography/Computer-Assisted Corneal Topography/ Photokeratoscopy
  • Amniotic Membrane and Amniotic Fluid
  • Bioengineered Skin and Soft Tissue Substitutes