Blue Cross Blue Shield of North Dakota (BCBSND) regularly develops and revises policies in response to rapidly changing medical technology. Our commitment is to update the provider community as 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. 21, 2021, and will be updated within the next 30-45 days on our website.
Medical Policies
The following medical policies are new:
The following medical policies were revised:
- Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
- Revision of not medically necessary wording:
- Instead of stating for any indication than listed above will be considered not medically necessary
- Will state not meeting the criteria as indicated in this policy is considered not medically necessary
- Revision of not medically necessary wording:
- Myoelectric Prosthetic Components for the Upper Limb
- Minimal verbiage change:
- Did state A prosthesis with individually powered digits
- Will state Hand prosthesis with individually powered and independently controlled myoelectric digits
- Minimal verbiage change:
- Lower Limb Prostheses
- Expanded an indication and added two not medically necessary statements
- Diagnosis and Treatment of Male Sexual Dysfunction
- Added two not medically necessary statements
- Moved how the procedure codes are displayed within the policy
- Cranial Orthosis for Plagiocephaly
- Added tables
- Revised not medically necessary statements
- Artificial Hearts and Ventricular Assist Devices
- Indicated U.S. FDA instead of FDA
- Expanded the definitions for medically necessary / FDA approved
- Changed the verbiage of the E/I statement
- Added tables
- Aqueous Shunts and Stents for Glaucoma
- Expanded what medical therapy definition
- Polysomnography (PSG) for Non-Respiratory Sleep Disorders
- Adding 4 bulleted points to criteria
- Transcatheter Pulmonary Valve Implantation
- Updated statement: Covered Diagnosis Codes for Procedure Code 33477
- Sacral Nerve Neuromodulation
- Revising how 2 statements are written:
- Indications and coverage did not change
- Revising how 2 statements are written:
- Posterior Tibial Nerve Stimulation
- Revising how 2 statements are written:
- Indications and coverage did not change
- Revising how 2 statements are written:
- Cognitive Rehabilitation
- Restructured how an E/I statement is written within the policy
- Tumor Treatment Fields
- Added in statement: not meeting the criteria as indicated in this policy
- Gastric Electrical Stimulation, Gastric Pacing
- Added in statement: not meeting the criteria as indicated in this policy, and for all other indications including, but not limited to, initial treatment of gastroparesis and treatment of obesity
- Esophageal pH Monitoring
- Adding evaluation of Dysphagia and adding Dx of Dysphagia to medically necessary criteria
- Heart Transplantation Adult and Pediatric
- Update to policy language
- Layout was updated
- No major changes to coverage or criteria
- Update to policy language
- Functional Neuromuscular Electrical Stimulation
- Policy updated with literature review through January 23, 2021
- References added
- Policy statements unchanged.
- Spinal Cord and Dorsal Root Ganglion Stimulation
- Added criteria for Removal of stimulator
- One time removal or revision of stimulator will be allowed per medical necessity criteria (i.e., current stimulator is out of warranty)
- Repeat removal or revision requests of stimulator will be reviewed by the Medical Director
- Removal of stimulator for technology upgrade when stimulator is still under warranty is not covered
- Added criteria for Removal of stimulator
- Deep Brain Stimulation
- ADDED A SECTION FOR: DBS is U.S. FDA HDE approved for the indication of bilateral stimulation of the anterior limb of the internal capsule, aic, in obsessive compulsive disorder (OCD) when ALL of the following criteria have been met:
- See criteria in policy
- ADDED A SECTION FOR: DBS is U.S. FDA HDE approved for the indication of bilateral stimulation of the anterior limb of the internal capsule, aic, in obsessive compulsive disorder (OCD) when ALL of the following criteria have been met:
- Bulking Agents for the Treatment of Urinary Stress Incontinence and Vesicoureteral Reflux
- Policy reorganization
- Language updates
- No change to criteria
- Home Dialysis Equipment and Supplies
- Changing verbiage to not meeting the criteria as indicated in this policy are considered not medically necessary
- Verbiage was: will be considered not medically necessary
- Added the words covered Dx codes
- Clinical Trials
- Added OR / And to policy statements
- Hematopoietic Cell Transplantation for Amyloid light-chain (AL) Amyloidosis (Primary Systemic Amyloidosis)
- Policy language updates
- Denial statements updated
- Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia
- Criteria updated
- Policy language updates: SUCH AS not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature
- Wearable Cardioverter-Defibrillator
- Updated policy languages
- No change to criteria
- Electrical Nerve Stimulation
- Language updated
- Criteria updated: see medical policy for specifics
- New criteria added: see medical policy for specifics
- Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
- Separated balloon kyphoplasty and mechanical vertebral augmentation statements out.
- Changed wording to Use FDA cleared device instead of Kiva.
The following medical policies are consent policies:
- Percutaneous Vertebroplasty and Sacroplasty
- Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
- Hematopoietic Cell Transplantation for Autoimmune Diseases
- Magnetoencephalography and Magnetic Source Imaging
- Implantable Pulmonary Artery Pressure Measurement Device
- Orthopedic Applications of Platelet-Rich Plasma
- Actinic Keratosis
- Photodynamic Therapy (PDT) with Porfimer Sodium
- Transcatheter Closure Devices for Septal Defects
- Ambulatory and Outpatient Cardiac Hemodynamic Monitoring of Heart Failure
- Ankle-Foot/Knee-Ankle-Foot Orthosis
- Chronic Pain Programs
- H-wave Electrical Stimulation
- Interferential Stimulator
- Oxygen
- Cardiac Rehabilitation Programs, Phase II Outpatient
- Devices Used for Treatment of Obstructive Sleep Apnea in Adults
- Pain Management of Peripheral Nerves by Injection
- Allergy Immunotherapy
- Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (LINX®)
- Bone Mineral Density Studies
The following medical policies had coding changes:
- Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
- Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease
- Powered Exoskeletal Robotic Systems
- Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemia
- Manipulation Under Anesthesia
- Autonomic Nervous System Function Testing
- Electroencephalogram (EEG) Technologies
- Tumor Markers (CA-125)
- Cognitive Rehabilitation
- High Frequency Chest Wall Oscillation Devices
- Wearable Cardioverter-Defibrillator
- Esophageal pH Monitoring
- Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy
- Deep Brain Stimulation
- Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia
- Durable Medical Equipment
- Experimental-Investigational
- Pneumatic Compression Devices
- Devices Used for Treatment of Obstructive Sleep Apnea in Adults
- Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals
- Amniotic Fluid and Amniotic Membrane
- Discography
- Nerve Conduction Studies and Electromyography
- Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
- Pheresis Therapy
- Enteral Nutrition
- Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
- Lower Limb Prostheses
- Posterior Tibial Nerve Stimulation
- Electrical Nerve Stimulation
- Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
- Polysomnography (PSG) for Non-Respiratory Sleep Disorders
The following medical policy has been archived:
