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 Dec. 16, 2025. To review our medical policy changes, visit our BCBSND website under Medical Policy Search | BCBSND.
The following medical policies are new:
- Non-Surgical Management of Nasal Airway Obstruction
The following medical policies were revised:
- Pain Management by Injection
- Under Policy Position Changed patient to individual and added ‘or’ to the first bullet point under Plantar fasciitis injection indications.
- Transcatheter Arterial Chemoembolization
- Under Policy Position - Removed confined to the liver, updated to liver-dominant.
- Removed symptomatic individuals and those whose symptoms persist despite systemic therapy
- Transcatheter Pulmonary Valve Implantation
- Updated acronyms in description. Under Policy Position – removed that was equal to or greater than 16 mm in diameter when originally implanted and 150 mL/ M2 to 160 mL/M2.
- Nerivio
- Age requirements changed from 12 to 8. Added electrical to description paragraph.
- Sacral Nerve Neuromodulation
- Updated Professional Statements and Societal Positions
- Manipulation Therapy
- Updated Manipulative Therapy and Musculoskeletal Disorders under the description.
- Updated criteria verbiage and removed Habilitative therapy section
- Radioembolization for Primary and Metastatic Tumors of the Liver
- Updated description
- Changed NCCN guidelines for Primary Hepatocellular Carcinoma, Metastatic Neuroendocrine Tumors, Metastatic Colon Cancer, and Metastatic Uveal Melanoma. Updated References
- Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
- Updated references, updated description
- Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
- Updated the description
- Updated guidelines under Professional Statements and Positions
- Updated References
- Allergy Skin Testing
- Removed Foods bullet point under Policy Position
- Updated Professional Statements and Societal Positions
- Ostomy Supplies
- Removed A6216 and quantity level limits for this code
- Non-Powered Negative Pressure Wound Therapy System
- Updated policy position
- Removed surgically closed incisions and added closed incision at high risk for wound complications
- Removed actively infected ulcer and added untreated or uncontrolled infection within the ulcer bed
- Added inadequate perfusion/ischemia, added onto document changes in the ulcer’s dimension and characteristics at least monthly bullet point; and
- Added not medically necessary paragraph. Added ‘continuation of’ to non-powered NPWT section
- Added not medically necessary paragraph to NPWT section
- Gender Affirmation Treatment
- Removed “the’ under the 1st and 3rd bullet point under gender affirming surgery may be medically necessary section
- Updated Professional Statements and Societal Positions section
- Prostate Disease: Diagnosis, Staging, and Treatment
- Updated HIFU section and continue to be medically necessary
- Added Prostatic Artery Embolization section as medical necessity
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Updated Policy Position DOP/DOS verbiage
- Updated Diagnosis and Practice Guidelines and Position Statements. Added North American Spine Association
- Added verbiage under American Society of Pain and Neuroscience
- Added verbiage under National Institute for Health and Care Excellence
- Removed table 18 and added table 19
- Coronary Revascularization
- Changed word for any to one or more
The following medical policies are consent policies:
- Nerve Conduction Studies and Electromyography
- External Counterpulsation
- Ambulatory and Outpatient Cardiac Hemodynamic
- Endoscopic Radiofrequency Ablation/ Cryotherapy
- Per-Oral Endoscopic Myotomy
- Transcatheter Mitral Valve Repair/ Replacement
- Vertebral Body Tethering
- Breast Ductal Lavage and Fiberoptic Ductoscopy
- Echosclerotherapy
- Subfascial Endoscopic Perforator Surgery (SEPS)
- Tumor Treatment Fields
- Endovenous Cryoablation
- Laser Treatment, Non- Invasive
- Breast MRI
- Radiofrequency Facet Denervation
- Apos Therapy System
- Ambulance Services: Ground Transportation
- Sports Physical
- Treatment of Malignant Skin Lesions
- Transanal Irrigation
- Occupational Therapy (OT)
- Allergy Immunotherapy
- Assisted Reproductive Technology
- Surgical Treatment of Varicose Veins
The following medical policies had coding changes:
- Posterior Tibial Nerve Stimulation
- Added procedure code E0736
- Removed procedure code E0737
- Bulking Agents for the Treatment of Urinary Stress
- Added diagnosis codes N13.729 and N13.739
- Cardiac Rehabilitation Programs, Phase II Outpatient
- Removed duplicate diagnosis code I24.89
- Electronystagmography (ENG) and Videonystagmography (VNG)
- Removed procedure code 92700 from covered diagnosis list
- Skin Substitutes
- January new codes that were added: Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, and Q4433
- Category III T Codes
- January new codes added: 0988T, 0989T, 0990T, 0991T, 0992T, 0993T, 0994T, 0995T, 0996T, 0997T, 0998T, 0999T, 1000T, 1001T,1002T, 1003T, 1004T, 1005T, 1006T, 1007T, 1008T, 1009T, 1010T, 1011T, 1012T, 1013T, 1014T, 1015T, 1016T, 1017T, 1018T, 1019T, 1020T, 1021T, 1022T, 1023T, and 1024T
- Cosmetic Surgery vs. Reconstructive Surgery
- Removed codes 17110, 17111, 17999, 96900 from port wine stain area of policy
- Removed termed code 15819
- Experimental/ Investigational
- January new codes added: 37262, 37279, 47384, 64654, 64655, 64656, 64657, 64658, 64659, 75577, 93145, 93146, 97007, 97008, 97009, C7568, C7569, C7570, C7571, and C9810
- Removed procedure codes: 30468, 30469
- Codes moved to new policy Z-110
- Prostate Disease: Diagnosis, Staging, and Treatment
- January new codes added: 52443, 52597, 55707, 55708, 55709, 55710, 55711, 55712, 55713, 55714, 55715, 55868, 55869, and 55877
- Remote Patient Monitoring (RPM)
- January new codes added: 99470, 99445, 98986, 98985, 98984, and 98979
- Tumor Treatment Fields
- January new code added: 1025T
- External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
- January new codes added: 92628, 92629, 92631, 92632, 92634, 92635, 92636, 92637, 92638, 92639, 92641, and 62942
- Urological Supplies
- January new codes added: A4295, A4296, and A9297
- Drug Testing
- January new codes added: 92628, 92629, 92631, 92632, 92634, 92635, 92636, 92637, 92638, 92639, 92641, and 92642
- Ilizarov Bone Lengthening
- January new codes added: 27458 and 27713
- Coronary Revascularization
- January new codes added: 92930 and 92945
- Bariatric Surgery
- January new code added: 43889
- Intensity-Modulated Radiotherapy of the Breast and Lung
- January new codes added 77407 and 77412
- Removed 77385, 77386, G6015, and G6016
- Intensity-Modulated Radiotherapy of the Prostate
- January new codes added 77407 and 77412
- Removed 77385, 77386 G6015, and G6016
- Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
- January new codes added 77407 and 77412
- Removed 77385, 77386, G6015, and G6016
- Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest
- January new codes added 77407 and 77412
- Removed 77385, 77386, G6015, and G6016
- Intensity-Modulated Radiotherapy: Central Nervous System Tumors
- January new codes added 77407 and 77412
- Removed 77385, 77386 G6015, and G6016
- Posterior Tibial Nerve Stimulation
- Added procedure E0736.
- Added section for codes E0736, E0737, and A4545 as not medically necessary
- Percutaneous Electrical Nerve Field Stimulation (PENFS)
- January new code added: 64567
- Removed 0720T
- Electrical Nerve Stimulation
- January new code added: C1607
- Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
- Added M50.00, M50.01, M50.020, M50.021, M50.022, M50.023, M50.03, M50.10, M50.11, M50.120, M50.121, M50.122, M50.123, M50.13, M50.20, M50.21, M50.220, M50.221, M50.222, M50.223, M50.23, M50.30, M50.31, M50.320, M50.321, M50.322, M50.323, M50.33, M50.80, M50.81, M50.820, M50.821, M50.822, M50.823, M50.83, M50.90, M50.91,M50.920, M50.921,M50.922, M50.923, M50.93, M51.360, M51.361, M51.362, M51.369, M51.370, M51.371, M51.372, and M51.379
- Removed M51.2, M51.3, M51.36, M51.37, M51.4, M51.8, M51.A0, M51.A1, M51.A2, M51.A3, M51.A4, and M51.A5
- Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
- Added M94.261, M94.262, M94.269, and S89.91XD to covered diagnosis
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Added 64625 to covered procedure codes
Additional Updates
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- On Jul. 3, 2023, codes 64582, 64583, and 64584 were removed from the policy but not documented
- Pneumatic Compression Devices
- Due to how benefit language written need to revert language back to original and to fit criteria for allowing chest and truck with limbs
