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 Oct. 13, 2026. To review our medical policy changes, visit our BCBSND website under Medical Policy Search.
The following medical policies are new:
The following medical policies were revised:
- Myoelectric Prosthetic Components for the Upper Limb
- Lower Limb Prostheses
- Hematopoietic Cell Transplantation: Solid Tumors
- Hematopoietic Cell Transplantation: Non-Cancer Diseases
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
- Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
- Small Bowel, Small Bowel/Liver and Multivisceral Transplant
- Sacral Nerve Neuromodulation
- Gender Affirmation Treatment
- External Hearing Aids, Auditory Brainstem Implant, Bone-Anchored Hearing Devices and Audiological Testing
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Reformatted criteria, added policy guidelines
- Kidney Transplant
- Intensity-Modulated Radiotherapy of the Breast and Lung
- Phototherapy for Psychiatric Disorders
- Thermography (Thermogram)
- Updated Professional Statement
- Manipulation Under Anesthesia
- Subfascial Endoscopic Perforator Surgery (SEPS)
- Echosclerotherapy
- Added Professional Statement
- Beds- Accessories and Related Items
- Intensity-Modulated Radiotherapy of the Prostate
- Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
- Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest
- Intensity-Modulated Radiotherapy: Central Nervous System Tumors
- Computerized Corneal Topography
- Removed "Follow-Up Evaluation of Keratoconus from Summary of Evidence, updated references
- Treatment of Benign or Premalignant Skin Conditions
- Updated criteria. Removed Diagnosis codes: D17.20, D22.20, D23.10, D23.20, D23.70, H02.823, H02.826
- Pneumatic Compression Devices
- Reformatted criteria, updated literature
- Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
- Reformatted criteria, added procedure code: 0665U
- Orthopedic Applications of Stem-Cell Therapy
- Electroencephalogram
- Updated skull to scalp in description, updated references. Removed I49.8, added I49.81, I49.82, and I49.89
- Devices Used for the Treatment of Obstructive Sleep Apnea in Adults and Pediatrics
- Updated criteria, removed procedure code E0471 from Pap rental section
- Oncologic Applications of Positron Emission Tomography Scanning
- Reformatted criteria, added procedure code: A9592, removed procedure codes: A9602, A9616, G0219
- Urological Supplies
- Updated criteria, added Procedure Codes A6590, E2001
- Diagnosis of Obstructive Sleep Apnea in Pediatric Individuals
- Updated criteria, literature, and description
- Single-Use (Disposable) Negative Pressure Wound Therapy (NPWT)
- Updated title: Single-Use (Disposable) Negative Pressure Wound Therapy (NPWT), Updated description, criteria and references
- Chelation Therapy for Off-Label Uses
- Added diagnosis codes: G20.A1, G20.A2, G20.B1, G20.B2, G20.C. Added Parkinson's disease to criteria. Updated references.
- Nerve Conduction Studies and Electromyography
- Updated literature, updated references
- Miscellaneous Services
- Removed procedure code: 74270. Removed Defecography from criteria
- Surgical Treatment of Obstructive Sleep Apnea
- Removed procedure code 42145 from non-covered diagnosis code and added to Covered diagnosis code. Added C9727 to experimental section for adults, and added Professional Statement
The following medical policies are consent policies:
- Subtalar Arthroereisis
- Ultra-Rapid Opiate Detoxification (UROD)
- Patient Lifts
- Diabetic Services and Supplies
- Cranial Electrotherapy Stimulation and Auricular Electrostimulation
- Seat Lift Mechanisms
- Pulmonary Rehabilitation
- Rabies Vaccination and Immune Globulin
- Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
- Chronic Pain Programs
- Peer Support
- Experimental/Investigational
- Implantable Pulmonary Artery Pressure Measurement Device
- Electromagnetic Navigational Bronchoscopy (ENB)
- Home Cervical Traction Therapy
- AposTherapy System
- Mobile Cardiac Outpatient Telemetry (MCOT)
- Chronic Wound Management
- Supplementary Algorithm for Cardiac Magnetic Resonance Imaging
- Occupational Therapy (OT)
- Ablation of Miscellaneous Solid Tumors
- Islet Cell Transplantation
- Cervical Spinal Fusion
- Frenectomy or Frenotomy for Ankyloglossia
- Axial Lumbosacral Interbody Fusion
- Intravascular Lithotripsy
- Fibrin Sealant
- Percutaneous Tenotomy
- Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)
- Eustachian Tube Balloon Dilation
- Endobronchial Valve Surgery
- Orthopedic Applications of Platelet-Rich Plasma
- Acellular Dermal Matrix Grafts
- Transcatheter Closure Devices for Septal Defects
- Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
- Discography
- Aqueous Shunts and Stents for Glaucoma
- Cardiac Ablation Procedures
- Treatment of Malignant Skin Lesions
- Endovenous Cryoablation
- Ligation, Division, and/or Excision of Varicose Vein Cluster(s)
- Ligation or Laser Ablation, Incompetent Perforator Veins
- Laser Treatment, Non-Invasive
The following medical policies had coding changes:
- Bariatric Surgery
- Removed procedure code C9784
- Skin Substitutes
- Added procedure codes: A2046, A2047, A2048, A2049, A2050. Q4207, Q4223, and Q4243
- Phrenic Nerve Stimulation
- Added procedure code: L8697, removed procedure code: L8696
- Experimental/Investigational Services
- Added procedure codes: A6614, E2403, G0685
- Ankle-Foot Knee-Ankle-Foot Orthosis
- Added procedure code: L1972. Remove diagnosis code: M72.2, added diagnosis codes: M67.A01, M67.A02, M67.A09, M72.20, M72.21, M72.22
- Braces and Supports
- Added procedure code: L1330
- Category III T Codes
- Added procedure codes: 1054T, 1055T, 1056T, 1057T, 1058T, 1059T, 1060T, 1061T, 1062T, 1063T, 1064T, 1065T, 1066T, 1067T, 1068T, 1069T, 1070T, 1071T, 1072T, 1073T, 1074T, 1075T, 1076T, 1077T, 1078T, 1079T, 1080T, 1081T, 1082T, 1083T, 1084T, 1085T, 1086T, 1087T, 1088T, 1089T, 1090T, 1091T, 1092T, 1093T, 1094T, 1095T, 1096T, 1097T, 1098T, 1099T, 1101T, 1102T, 1103T, 1106T, 1108T, 1109T, 1110T, and 1111T. Removed references.
- Diagnosis of Obstructive Sleep Apnea in Adults
- Removed diagnosis code: I49.8. Added diagnosis codes: I49.81, I49.82, I49.89
- Wearable Cardioverter-Defibrillator
- Added diagnosis codes: I42.00, I42.01, I42.09, I42.81, I42.89. Removed diagnosis codes: I42.0, I42.8
- Foot Orthotics for Conditions Other Than Diabetes
- Added diagnosis code: M67.A01, M67.A02, M67.A09, M72.20, M72.21, and M72.22. Removed diagnosis code: M72.2. Updated References.
- Fecal Microbiota Transplantation
- Added diagnosis code: Z86.17
- Physical Therapy
- Added diagnosis codes to covered diagnosis for procedure code 97016: I87.31X, I87.32X, I87.33X, I87.39X, I87.3XX, S80.81XA, S80.82XA, S80.91XA, S80.92XA, Z90.12, Z90.13.
- Added diagnosis codes to covered diagnosis for procedure code 97116: I69.351, I69.352, M21.56.
- Added diagnosis codes to covered diagnosis for procedure codes S9476, 95992, 97110, 97112, 97530: F87.01, G44.1, G45.0, G45.1, G45.2, G45.3, G45.8, G45.9, G90.9, G96.1, H81.01, H81.02, H81.03, H81.31, H81.32, H81.33, H81.42, H81.8X1, H81.8X2, H81.8X3, H81.9, H81.91, H81.92, H81.93, I60.01, I60.09, I60.11, I60.12, I60.2, I60.3, I60.4, I60.5, I60.6, I60.8, I60.9, I61.1, I61.3, I61.4, I61.5, I61.6, I61.8, I62.1, I62.9, I63.00, I63.01, I63.02, I63.341, I63.342, I63.39, I63.40, I63.411, I63.412, I63.421, I63.422, I63.431, I63.432, I63.441, I63.442, I63.443, I63.511, I63.512, I63.521, I63.522, I63.531, I63.532, I63.541, I63.542, I63.6, R42, S06.0X0A, S06.0X1A, S06.0X9A
- Gastric Electrical Stimulation, Gastric Pacing
- Added diagnosis codes: E08.43, E09.43, E10.43, E11.43, E13.43
- Autonomic Nervous System Function Testing
- Added diagnosis codes: I49.81, I49.82, I49.89. Removed diagnosis code: I49.80
- Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease
- Added procedure code: 83630
- Intraepidermal Nerve Fiber Density Testing
- Add procedure codes: 88313, 88346, 88350. Updated references
- Apheresis Therapy
- Added diagnosis codes: I42.00, I42.09 to two different sections for covered diagnosis codes for procedure codes: 36512, 36513, 36514, 36516, and covered diagnosis codes for procedure codes 36516, S2120. Added diagnosis codes: D57.04, D57.1, D57.214, D57.414, D57.434, D57.454, D57.84 for covered diagnosis codes for procedure codes: 36512, 36513, 36514, 36516. Removed diagnosis codes: D57.04, D57.1, D57.214, D57.414, D57.434, D57.454, D57.84 for covered diagnosis codes for procedure codes: 36511
The following medical policies will be archived/retiring:
- No archived policies this IMPC
The following medical policies have been updated:
- Wearable Cardioverter-Defibrillator
- Added back subsequent criteria to policy
- Physical Therapy
- Added diagnosis codes for procedure code 97116: S82.41A, S82.41B, S82.41C, S82.41D, S82.41E, S82.41F, S82.41G, S82.41H, S82.41J, S82.41K, S82.41M, S82.41N, S82.41P, S82.41Q, S82.41R, S82.41S, S82.42A, S82.42B, S82.42C, S82.42D, S82.42E, S82.42F, S82.42G, S82.42H, S82.42J, S82.42K, S82.42M, S82.42N, S82.42P, S82.42Q, S82.42R, S82.421S
The following medical policies have been tabled:
- Tumor Markers
- Further research is needed.
