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 Sept. 4, 2025. To review our medical policy changes, visit our BCBSND website under Medical Policy Search | BCBSND. 

The following medical policies are new:

  • Interferential Current Stimulation
  • Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
  • Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine
  • Percutaneous Tenotomy
  • Kidney Transplant

The following medical policies were revised:

  • Non-spinal Bone Growth Stimulation
  • Corneal Surgery to Correct Refractive Errors and Phototherapeutic Keratectomy, and Corneal Collagen Cross-Linking
  • Gastric Electrical Stimulation, Gastric Pacing
  • Chronic Wound Management
  • Apheresis Therapy
  • Hematopoietic Cell Transplantation: Blood Cancers
  • Lower Limb Prostheses
  • Endoscopic Stricturotomy
  • Laminectomy
  • Percutaneous Electrical Nerve Field Stimulation (PENFS)
  • Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome
  • External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
  • Treatment of Abnormal Uterine Bleeding and Uterine Fibroids
  • Negative Pressure Wound Therapy Pumps/Vacuum Assisted Closure of Chronic Wounds
  • Electrical Nerve Stimulation
  • Non-Powered Negative Pressure Wound Therapy System
  • High Frequency Chest Wall Oscillation Devices
  • Nebulizers
  • Miscellaneous Services
  • Surgical Treatment of Varicose Veins

The following medical policies are consent policies:

  • Powered Exoskeletal Robotic Systems
  • Intense Pulsed Light Therapy for the Treatment of Dry Eye Disease
  • General Anesthesia for Oral and Maxillofacial Surgery and Dental Services (Medicaid Expansion)
  • Remote Patient Monitoring RPM
  • Ultra-Rapid Opiate Detoxification (UROD)
  • Cranial Electrotherapy Stimulation and Auricular Electrostimulation
  • H-wave Electrical Stimulation
  • Interferential Stimulator
  • Pain Management by Injection
  • Manipulation Services (Medicaid Expansion)
  • Biofeedback
  • Electrical Stimulation Devices for Treatment of Arthritis
  • Basivertebral Nerve Ablation
  • Intensity-Modulated Radiotherapy of the Breast and Lung
  • Autonomic Nervous System Function Testing
  • Photography
  • Surgical Treatments for Breast Cancer-Related Lymphedema
  • Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
  • Ligation or Ablation, Incompetent Perforator Veins
  • Proton Beam Radiation Therapy - FM HomeBuilders Consortium and Eide Bailly only
  • Per-Oral Endoscopic Myotomy
  • Lipedema
  • Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography
  • Composite Tissue Allotransplantation of the Hand
  • Pancreas Transplant
  • Ocular Photodynamic Therapy
  • Corneal Transplantation
  • Heart-Lung Transplantation
  • Treatment of Malignant Skin Lesions
  • Nucleoplasty and Biacuplasty
  • Intraocular Lens
  • Chromoendoscopy as an Adjunct to Colonoscopy
  • Nerve Ablation and Injection
  • Automated External Defibrillators for Home Use
  • Thermography (Thermogram)
  • Covid-19 Antibody Testing
  • Home Health- Extended Hours
  • Hospice
  • Hospice (Medicaid Expansion)
  • Measurement of Serum Antibodies to Selected Biologic Agents
  • Eustachian Tube Balloon Dilation
  • Endobronchial Valve Surgery
  • Electronystagmography (ENG) and Videonystagmography (VNG) Services
  • Measurement of Exhaled Nitric Oxide
  • Esophageal pH Monitoring
  • Ambulatory Blood Pressure Monitoring
  • Prophylactic Mastectomy
  • Endoscopic Radiofrequency Ablation/Cryotherapy
  • Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Condition
  • Chelation Therapy for Off-Label Uses
  • Cerebral Oxygenation Monitoring using Near Infrared Spectroscopy (NIRS)
  • Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease
  • Subtalar Arthroereisis
  • Repair, Maintenance, and Replacement of Durable Medical Equipment (DME)
  • Transcatheter Pulmonary Valve Implantation
  • Urological Supplies
  • Nerve Conduction Studies and Electromyography
  • Beds - Accessories and Related Items
  • Durable Medical Equipment (DME)
  • Cardiac Ablation Procedures
  • Lung and Lobar Lung Transplant

The following medical policies had coding changes:

  • Devices Used for the Treatment of Obstructive Sleep Apnea in Adults
    • Added July New Codes 0964T, 0965T, and 0966T
  • Experimental/Investigational
    • Added July New Codes 0948T, 0949T, 0951T, 0952T, 0953T, 0954T, 0955T, 0956T, 0957T, 0958T, 0959T, 0960T, 0961T, 0962T, 0963T, 0967T, 0968T, 0969T, 0970T, 0971T, 0972T, 0973T, 0974T, 0975T, 0976T, 0977T, 0978T, 0979T, 0980T, 0981T, 0982T, 0983T, 0984T, 0985T, 0986T, and 0987T
    • Removed codes 31242, 31243, C9762, and C9763
  • Amniotic Membrane and Amniotic Fluid
    • Added July New Codes Q4368, Q4369, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, and Q4382
  • Orthopedic Applications of Stem-Cell Therapy
    • Replaced code A4694 with A4649
  • Bioengineered Skin and Soft Tissue Substitutes
    • Added Q4370 and Q4371
    • Moved Q4158 from experimental to its own section
    • Added covered diagnosis codes E08.621-E13.9 to procedure code Q4158
  • Prostate Disease: Diagnosis, Staging, and Treatment
    • Added 0950T
  • Amniotic Membrane and Amniotic Fluid
    • Added Diagnosis Codes: L97.912, L97.913, L97.914, L97.15, L97.916, L97.918, L97.921 for covered section: Procedure codes Q4132, Q4151, Q4154, Q4159, Q4168 and Q4186
  • Bone Mineral Density Studies
    • Added diagnosis code M80.8B2S
  • Monitored Anesthesia Care
    • Removed diagnosis codes C15.3, C15.4, C15.5, C15.8, C15.9, C16.0, C16.1, C16.2, C16.3, C16.4, C16.5, C16.6, C16.8, C16.9, C17.0, C17.1, C17.2, C17.3, C17.8, C17.9, C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C21, C21.0, C21.1, C21.2, C21.8, C22.0, C22.1, C22.2, C22.3, C22.4, C22.7, C22.8, C22.9, C23, C24.0, C24.1, C24.8 ,C24.9, C25.0, C25.1, C25.2, C25.3, C25.4, C25.7, C25.8, C25.9, C26.0, C26.1, C26.9, Z85.07, and Z85.09.
    • Added Diagnosis Codes D13.9, M79.60, and Z12.2
  • Spinal Cord and Dorsal Root Ganglion Stimulation
    • Removed diagnosis codes: G90.51, G90.519, G90.52, G90.529, M25.51, M25.519, M25.52, M25.529, M25.53, M25.539, M25.54, M25.549, M25.55, M25.559, M25.56, M25.569, M25.57, M25.579, M79.62, M79.629, M79.63, M79.639, M79.64, M79.643, M79.646, M79.65, M79.659, M79.66, M79.669, M79.67, M79.673, M79.676, and R52.
  • Aqueous Shunts and Stents for Glaucoma
    • Removed procedure codes 0671T, 0376T (1st section of diagnosis codes)
    • Added 0474T and 0671T (2nd set of diagnosis codes)
  • Temporomandibular Joint (TMJ) Dysfunction
    • Added procedure code 20605
  • Knee Orthosis
    • Added procedure code L2861
  • Category III T Codes
    • Removed procedure codes 0338T, 0039T, 0783T, and 0308T
  • Wheelchairs and Options/Accessories
    • Removed procedure code E2298
  • Myocardial Strain Imaging
    • Added procedure codes C9762 and C9763
  • Discectomy
    • Added diagnosis codes M51.A0-M51.A5
  • Discography
    • Added diagnosis code M51.16
  • Cranial Orthosis for Plagiocephaly
    • Added diagnosis code Q75.051
  • Transanal Irrigation
    • Added diagnosis code K59.2

The following medical policies will be archived / retiring:

  • Percutaneous Electrical Nerve Field Stimulation (PENFS)
  • Interferential Stimulator
  • Percutaneous Left Atrial Appendage Closure Devices
  • Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
  • Percutaneous Vertebroplasty and Sacroplasty
  • Pap Smears with Medical Conditions
  • High Resolution Anoscopy (HRA)
  • Kidney Transplant