Medical Policy Available Online

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


Radioembolization for Primary and Metastatic Tumors of the Liver


The following medical policies had coding changes:


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)



The following medical policy has been archived:

Pancreas/Kidney Transplantation