Blue Cross Blue Shield of North Dakota 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 January 19, 2021. Please see policy for changes, which can be found online here.
The following medical policies are new:
Bronchial Thermoplasty
Kidney Transplant
The following medical policies were revised:
Cochlear Implantation
Gender Affirmation Surgery
Hyperbaric Oxygen Therapy
Amniotic Fluid and Amniotic Membrane
Cardiac Monitors
Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
Chronic Wound Management
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
Foot Care Services
Diagnosis and Treatment of Obstructive Sleep Apnea for Adults
Pheresis Therapy
Lung and Lobar Lung Transplant
Urological Supplies
The following medical policies are consent policies:
Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
Clinical Trials
Cleft Palate/Lip Reconstruction
Ambulance Services: Air and Water Transportation
Ambulance Services: Ground Transportation
Non-Spinal Bone Growth Stimulation
Medication Assisted Treatment (MAT)
Diagnosis and Treatment of Male Sexual Dysfunction
CT (Virtual) Colonoscopy
Artificial Intervertebral Disc Replacement
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
Dry Needling of Myofascial Trigger Points
Extracorporeal Photopheresis
In Vitro Allergy Testing
Intra-Arterial/Intravenous Therapeutic Procedures
Vitamin D Assay
Treatment of Abnormal Uterine Bleeding and Fibroids
Ultraviolet Light Therapies
Surgical Treatment of Femoroacetabular Impingement
Electroretinography
Radioembolization for Primary and Metastatic Tumors of the Liver
The following medical policies had coding changes:
Experimental/Investigational
Eustachian Tube Balloon Dilation
Treatment of the Prostate
Electronystagmography (ENG) and Videonystagmography (VNG) Services
Manipulation Services
Artificial Hearts and Ventricular Assist Devices
Pulmonary Rehabilitation
Drug Testing
Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
Oncologic Applications of Positron Emission Tomography Scanning
Electroencephalogram (EEG) Technologies
Axial Lumbosacral Interbody Fusion
Bioengineered Skin and Soft Tissue Substitutes
Home Pulse Oximetry Device
Nerve Conduction Studies and Electromyography
Allergy Skin Testing
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
Endoscopic Radiofrequency Ablation/Cryotherapy
Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)
Nebulizers
The following medical policy has been archived:
Pancreas/Kidney Transplantation