October/November 2024 Medical Policies Updates

Blue Cross Blue Shield of North Dakota (BCBSND) 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 Sept. 19, 2024. To review our medical policy changes, visit our BCBSND website under medical policies.

The following medical policies were revised:

  • Negative Pressure Wound Therapy Pumps/Vacuum Assisted Closure of Chronic Wounds
    • Policy verbiage updated, Updated Professional Statements
  • Non-Powered Negative Pressure Wound Therapy System
    • Policy verbiage updated, removal of treatment of children from birth up to and including 12 years of age is considered experimental/ investigational
  • High Frequency Chest Wall Oscillation Devices
    • Policy verbiage updated
  • Ankle-Foot/Knee-Ankle-Foot Orthosis
    • Policy criteria updated
  • Cosmetic Surgery vs Reconstructive Surgery
    • Added Morpheus8V to the policy always cosmetic section of policy
  • Sacral Nerve Neuromodulation
    • Policy criteria updated
  • Transcatheter Pulmonary Valve Implantation
    • Policy criteria updated
  • Mastectomy and Reconstructive Surgery
    • Verbiage changes
  • Nerve Conduction Studies and Electromyography
    • Criteria added
  • Dynamic Splinting Devices
    • Criteria reworded
  • Drug Testing
    • Quantity level limits removed for G0480, G0481, G0482, G0483, G0659, 80375, 80376 and 80377 were removed.
  • Bioengineered Skin
    • Removed bullet from TheraSkin section of policy


The following medical policies are consent policies:

  • H-Wave Electrical Stimulation
  • Interferential Stimulator
  • Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)
  • Endoscopic Radiofrequency Ablation/Cryotherapy
  • Electronystagmography (ENG) and Videonystagmography (VNG) Services
  • Discography
  • Treatment of Malignant Skin Lesions
  • Non-spinal Bone Growth Stimulation
  • Subtalar Arthroereisis
  • Beds - Accessories and Related Items
  • Esophageal pH Monitoring
  • Cranial Orthosis for Plagiocephaly
  • High Frequency Chest Wall Oscillation Devices


The following medical policies had coding changes:

  • Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover
    • Corrected typos for diagnosis codes
  • Negative Pressure Wound Therapy Pumps/Vacuum Assisted Closure of Chronic Wounds
    • The following diagnosis codes have been removed; From the 'For Stage III and IV Pressure Ulcers' Section L89.003, L89.004, L89.103, L89.104, L89.203, L89.204, L89.303, L89.304, L89.503, L89.504, L89.603, L89.604, L89.93, and L89.94
    • From the first and one of the following' Section L97.101, L97.102, L97.103, L97.104, L97.105, L97.106, : L97.10, L97.109, L97.201 and L97.202
    • From the first 'AND one of the following' Section:
      • L97.101, L97.102, L97.103, L97.104, L97.105, L97.106, L97.108, and L97.109
      • L97.201, L97.202, L97.203, L97.204, L97.205, L97.206, L97.207, L97.208, and L97.209
      • L97.301, L97.302, L97.303, L97.304, L97.305, L97.306, L97.308, and L97.309
      • L97.401, L97.402, L97.403, L97.404, L97.405, L97.406, L97.407, L97.408, and L97.409
      • L97.501, L97.502, L97.503, L97.504, L97.505, L97.506, L97.508, and L97.509
      • L97.801, L97.802, L97.803, L97.804, L97.805, L97.806, L97.808, and L97.809
      • L97.901, L97.902, L97.903, L97.904 L97.905, L97.906, and L97.908
    • From the 'For venous ulcer of lower extremity, other than pressure ulcer' Section: I83.001, I83.002, I83.003, I83.004, I83.005, I83.008, I83.009, I83.201, I83.202, I83.203, I83.204, I83.205, I83.208 and I83.209
    • From the 'OR' Section: I87.319 and I87.339
    • From the SECOND 'AND one of the following' Section
      • L97.101, L97.102, L97.103, L97.104, L97.105, L97.106, L97.108, and L97.109
      • L97.201, L97.202, L97.203, L97.204, L97.205, L97.206, L97.207, L97.208, and L97.209
      • L97.301, L97.302, L97.303, L97.304, L97.305, L97.306, L97.308, and L97.309,
      • L97.401, L97.402, L97.403, L97.404, L97.405, L97.406, L97.407, L97.408, and L97.409
      • L97.501, L97.502, L97.503, L97.504, L97.505, L97.506, L97.508, and L97.509
      • L97.801, L97.802, L97.803, L97.804, L97.805, L97.806, L97.808, and L97.809
      • L97.901, L97.902, L97.903, L97.904 L97.905, L97.906, and L97.908
    • From the 'Complications of a surgically created wound' Section: T81.4XXA;
    • From the 'Open wound of upper or lower limb, complicated' Section:
      • S41.009A, S41.029A, S41.049A, S41.109A, S41.129A, S41.149A,
      • S51.009A, S51.029A, S51.049A, S51.809A, S51.829A, S51.849A
      • S61.509A, S61.529A, S61.549A
      • S71.029A, S71.049A, S71.129A, S71.149A
      • S81.029A, S81.049A, S81.829A, S81.849A
      • S91.029A, S91.049A, S91.329A and S91.349A
    • The following diagnosis codes have been added; From the 'Complications of a surgically created wound' Section: T81.42XA and T81.42XD.
    • Non-Powered Negative Pressure Wound Therapy System
    • Removed Diagnosis Codes:
      • L83.001, L83.002, L83.003, L83.004, L83.005, L83.008, L83.009
      • L83.201, L83.202, L83.203, L83.204, L83.205, L83.208, L83.209
      • L87.319,L89.003, L89.004, L89.103, L89.104, L89.203, L89.204, L89.303, L89.503, L89.504,L89.603, L89.604,L89.93, L89.94
      • L97.201, L97.202, L97.203, L97.204, L97.209
      • L97.301, L97.302, L97.303, L97.304, L97.309
      • L97.401, L97.402, L97.403, L97.404, L97.409
      • L97.501, L97.502, L97.503, L97.504, L97.509
      • L97.801, L97.802, L97.803, L97.804, L97.809
      • L97.901, L97.902, L97.903, L97.904, and L97.909
    • High Frequency Chest Wall Oscillation Devices
      • Added Diagnosis codes:
      • A80.0, A80.1, A80.2, A80.39, A80.4
      • E74.02, E74.04
      • G12.25, G72.41, G73.1, G80.0, G80.1, G80.2, G80.3, G80.8, R53.2, and Z99.11
      • Removed Diagnosis Codes: E84.9, G12.9, G12.20, G12.29, G71.0, G71.00, G71.20, and G82.50
  • Ankle-Foot/Knee-Ankle-Foot Orthosis
    • Added procedure code: L2006
    • Removed diagnosis code: M14.69
  • Cosmetic Surgery vs Reconstructive Surgery
    • Added code: E0730
  • Sacral Nerve Neuromodulation
    • Added procedure code L8679 to urinary and fecal incontinence sections. HCPCS codes added: C1820, C1822, C1823, C1826, and C1827
  • Eustachian Tube Balloon Dilation
    • Removal of unspecified side diagnosis codes H68.009, H68.029, H69.80, and H69.90
  • Per-Oral Endoscopic Myotomy (POEM)
    • Update unlisted procedure code from 43499 to 43999
  • Experimental/Investigational
    • Removed procedure code L2006
  • Mastectomy and Reconstructive Surgery
    • Removed deleted procedure code 19324
  • Dynamic Splinting Devices
    • Removal of duplicate diagnosis codes and creation of diagnosis grid for Procedure code E1820
  • Telehealth
    • Removed non-covered procedure codes 98966, 98967, and 98968
  • Durable Medical Equipment
    • Removed diagnosis codes (unspecified side) from procedure codes A6410, A6411, and A4612:
    • Removed: H49.00. H49.10, H49.20, H49.30, H49.40, H49.889, H50.629, H50.639, H50.659, H50.669. H50.679, and H50.689
  • Biomarkers in Risk Assessment and Management of Cardiovascular Disease
    • Removed deleted diagnosis code I50.510.
  • Bioengineered Skin
    • Removed covered diagnosis codes for procedure code Q4121:
      • C43.0, C43.111, C43.112, C43.121, C43.122, C43.21, C43.22, C43.31, C43.39, C43.4, C43.51, C453.52, C43.59, C43.61, C43.62, C43.71, C43.72, and C43.8
      • C44.00, C44.01, C44.02, C44.192, C44.199, C44.202, C44.209, C44.212, C44.219, C44.222, C44.301, C44.399, C44.40, C44.41, C44.42, C44.49,
      • C44.500, C44.501, C44.509, C44.510, C44.511, C44.519, C44.520, C44.521, C44.529, C44.590, C44.591, C44.599,
      • C44.602. C44.609, C44.612, C44.619, C44.622, C44.629, C44.699
      • C44.702, C44.709, C44.81, C44.82, C44.89, C79.2
      • D03.0, D03.111, D03.112, D03.122, D03.21, D03.22, D03.39, D03.4, D03.51, D03.52, D03.59, D03.61, D03.62
      • D03.71, D03.72, D03.8, D04.0, D04.111, D04.112, D04.121, D04.122, D04.21, D04.22, D04.39, D04.4, D04.5, D04.61, D04.62, D04.71, D04.72, and D04.8
  • Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
    • Removed diagnosis codes:
      • L89.003, L89.004, L89.103, L89.104, L89.203, L89.204, L89.303, L89.304, L89.503, L89.504, L89.603, L89.604, L89.94
      • L97.102, L97.103, L97.104, L97.105, L97.108, L97.202, L97.203, L97.204, L97.205, L97.2026, L97.208
      • L97.302, L97.303, L97.304, L97.305, L97.306, L97.308, L97.402, L97.403, L97.404, L97.405, L97.406, L97.408
      • L97.502, L97.503, L97.504, L97.505, L97.506, L97.508
      • L97.802, L97.803, L97.804, L97.806, L97.808, L97.902, L97.903, L97.904, L97.905, L97.906, and L97.908.
    • Removed duplicate diagnosis code L89.94
  • Cranial Electrotherapy Stimulation and Auricular Electrostimulation
    • Added October new codes A4543 and E0721
  • Amniotic Membrane and Amniotic Fluid
    • Added diagnosis codes H16.231, H16232, and H16233 to procedure code 65778
  • Nerve Conduction Studies and Electromyography
    • October new codes; added diagnosis codes G90.81, G90.89, M62.85
    • Removed diagnosis code G90.8.
  • Electroencephalogram
    • October new codes adding diagnosis codes: E74.820, E74.829, G40.841, G40.842, G40.843, G40.844, G90.81, G90.89, and G93.45.
    • Removed diagnosis code G90.8.
    • Corrected typo, diagnosis code G43.43 should have been G93.43.
  • Autonomic Nervous System Function Testing
    • October New Codes, added diagnosis codes G90.81 and G90.89
    • Removed diagnosis code G90.8
  • Ambulatory Blood Pressure Monitoring
    • October new codes; adding diagnosis codes E66.811, E66.812, and E66.813.
    • Removing diagnosis code E66.8.
  • Nebulizer
    • October new codes; adding A7021 and E0469
  • Bioengineered Skin and Soft Tissue Substitutes
    • October new codes; adding new codes A2027, A2028, and A2029
  • Speech Generating Devices
    • October new codes, adding diagnosis code E2513
  • Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
    • October new codes; adding diagnosis codes G40.841, G40.842, G40.843, G40.844, M51.360, M51.361, M51.362, M51.369, M51.370, M51.371, MN51.372, and M51.379
    • Fixed typo 95886 should be 95868.
  • Prophylactic Mastectomy
    • October new codes; adding diagnosis codes Z17.410 and Z17.420
  • Negative Pressure Wound Therapy Pumps/Vacuum Assisted Closure of Chronic Wounds
    • October new codes; adding diagnosis codes T81.329A, T81.32D and T81.329S
    • Removing diagnosis codes T81.32XA and T81.32XD to/from the 'Complications of a Surgically Created Wound'.
  • Non-Powered Negative Pressure Wound Therapy System
    • October new codes; adding diagnosis codes T81.320A, T81.320D, T81.320S, T81.321A, T81.321D, T81.321S, T81.328A, T81.328D, T81.328S, T81.329A, T81.329D and T81.329S
  • Bariatric Surgery
    • October new codes: adding new diagnosis codes to covered procedure codes 43644, 43770, 43775, 43843, 43846, and S2083: E66.812, E66.813, Z68.55, and Z68.56.
    • Adding new diagnosis codes to non-covered diagnosis codes E33.811, E66.89 and removing diagnosis code E66.8.
  • Tumor Markers
    • October new codes; added diagnosis codes for procedure code 86316: E34.00, E34.01, and E34.09. Removed diagnosis code E34.0.
  • Powered Exoskeletal Robotic Systems
    • October new codes, adding procedure codes L8720 and L8721
  • Braces and Supports
    • October new codes: adding procedure codes L1006 and L1653.
  • Knee Orthosis
    • October new codes, adding procedure code L1821
  • Pheresis Therapy
    • October new codes; adding diagnosis code C88.00 to procedure codes 36512, 36513, and 36514
    • Removing diagnosis code C88.0 from procedure codes 36512, 36513, and 36514
    • Adding diagnosis codes C88.00 and C88.80 to procedure code 36511
    • Removing diagnosis codes C88.0 and C88.8 from procedure code 36511.Updated diagnosis codes; Adding diagnosis codes D57.454 and D57.814 to procedure code 36522 (Policy only)
    • Adding diagnosis codes D57.04, D57.214, D57.414, D57.434, D57.454, D57.814 to procedure code 36511
    • Removing diagnosis code N06.2 from procedure code 36511
    • Adding diagnosis codes D57.04, D57.214, D57.414, D57.434, D57.454, D57.814 to procedure codes 3516 and S2120
  • Discography
    • October new codes; adding diagnosis codes M51.360, M51.361, M51.362, M51.36, M51.370, M51.371, M51.372, and M51.3789.
    • Removing diagnosis codes M51.36 and M51.37.
  • Hematopoietic Cell Transplantation: Non-Cancer Diseases
    • October new codes; adding diagnosis code D61.03 to procedure codes 38205, 38230, 38240, S2140, S2142, and S2150
  • Bone Mineral Density Studies
    • October new codes, adding diagnosis codes F50.010, F50.011, F50.012, F50.013, F50.014, F50.019, F50.020, F50.021, F50.022, F50.024, F50.029, F50.20, F50.21, F50.22, F50.23, F50.24, F50.25, F50.810, F80.811, F50.812, F50.813, F50.814, F50.819 and M80.0B2S
    • Removing diagnosis codes F50.01, F50.02, F50.2, and F50.81
  • Ultraviolet Light Therapies Ultraviolet Light Therapies
    • October new codes; adding diagnosis codes L29.81, L29.89, L66.10, L66.11, L66.12, L66.19
    • Removing diagnosis codes L29.8 and L66.1 for procedure codes 96900, 96912, and 96913.
    • Adding diagnosis codes L66.10, L66.11, L66.12, L66.19 and removing L66.1 for procedure codes 96910, 96913, E0691, E0692, E0693, and E0694.
  • Electrical Nerve Stimulation
    • October new codes; adding non-covered diagnosis code M62.85 to 64555, 64575, 64590, 64999, L8679, L8680, L8681, L8683, L8688
  • Experimental/Investigational
    • October new codes; adding procedure codes A5444, E0743, E3200, C8000, E0683, E0767, 0479U, 0482U, 0490U, 0491U, 0492U, 0511U, 0512U, and 0513U