Migrated Medical Policy Search

Introduction

The purpose of a medical policy is to provide guidelines for determining coverage criteria for specific medical and behavioral health technologies, including procedures, equipment, and services. The same process is used to evaluate medical and behavioral health technologies. In order to be eligible for coverage, all services must be medically necessary (unless otherwise provided in the member's benefits contract). To the extent that there are any conflicts between medical policy guidelines and applicable contract language, the contract language takes precedence. Medical policy is not intended to override the health insurance contract that defines the insured’s benefits, nor is it intended to dictate to providers how to practice medicine. Physicians and other health care providers are expected to exercise their medical judgment in providing the most appropriate care.

Policy development

Selection of technologies for policy development

Issues are selected for medical policy development through referrals from staff, physicians, provider communities, and members. Priority may be given to the following:

New diagnostic tests, therapeutic procedures, or medical devices for which no other good alternatives exist;
Medical technologies that may have a safety concern;
Medical technologies that are considered life-saving;
Medical technologies that are controversial with respect to their clinical utility;
Medical technologies that have generated a high level of interest; and
New information published in the peer-reviewed scientific literature that may change the status of a technology from investigational to medically necessary.

Research sources

The following sources are considered in the development and revision of medical policy:

Technology assessments publicly published and based on a systematic review of the evidence (e.g., BlueCross BlueShield Association, BlueCross BlueShield Center for Clinical Effectiveness, Agency for Healthcare Research and Quality);
Peer-reviewed publications;
Evidence-based clinical practice guidelines developed by national organizations and other recognized authorities;
Generally accepted standards of medical practice;
External practicing physician review; and
Government approval status.

Definition of medical necessity

Medically necessary or medical necessity means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating illness, injury, disease or its symptoms, and that are:

a. In accordance with generally accepted standards of medical practice;
b. Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
c. Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

Generally accepted standards of medical practice

Generally accepted standards of medical practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, the views of physicians practicing in relevant clinical areas, and any other relevant factors.

Definition of investigational services

"Investigational" means that the medical technology does not meet the technology assessment criteria outlined below. If any of the criteria are not met, the technology is determined to be investigational. In addition, all services specifically associated with the investigational technology, including but not limited to associated procedures, treatments, supplies, devices, equipment, facilities or drugs, will also be considered investigational.

Technology assessment process

The technology assessment process is applied to both the development of new medical policies and existing policies. In order to determine whether a medical technology may be considered medically necessary, literature searches are conducted, and the published scientific evidence related to each technology is reviewed against five technology assessment criteria. The technology is considered investigational if any one or more of the criteria below are not met.

The technology must have final approval from the appropriate government regulatory bodies.
- This criterion applies to drugs, biological products, devices and any other product or procedure that must have final approval to market from the U.S. Food and Drug Administration (FDA) or any other federal governmental body with authority to regulate the technology.
- Any approval that is granted as an interim step (i.e., Treatment IND) by the FDA or any other federal governmental body’s regulatory process is not sufficient.
The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
- The evidence should consist of well-designed and well-conducted investigations published in peer-reviewed journals. The quality of the body of studies and the consistency of the results are considered in evaluating the evidence.
- The evidence should demonstrate that the technology can measure or alter the physiological changes related to a disease, injury, illness or condition. In addition, there should be evidence or a convincing argument based on established medical facts that such measurement or alteration affects the health outcomes.
- Opinions and evaluations by national medical associations, consensus panels or other technology evaluation bodies are evaluated according to the scientific quality of the supporting evidence and rationale.
The technology must improve the net health outcome.
The technology’s beneficial effects on health outcomes should outweigh any harmful effects on health outcomes.
The technology must be as beneficial as any established alternatives.
The technology should improve the net health outcome as much as or more than established alternatives.
The improvement must be attainable outside the investigational settings.
When used under the usual conditions of medical practice, the technology should be reasonably expected to satisfy technology evaluation criteria #3 and #4.

In addition to the above criteria, the following additional criteria apply to new diagnostic technologies (e.g., imaging studies, laboratory procedures, home monitoring devices):

Technical feasibility is demonstrated, including reproducibility and precision. For comparison among studies, a common standardized protocol for the new diagnostic technology is established.
For accurate interpretation of study results, sensitivities, specificities, and positive and negative predictive values compared to standards are established.
The clinical utility of a diagnostic technique, i.e., how the results of the study can be used to benefit patient management, is established. The clinical utility of both positive and negative tests must be established.

External physician review

BCBSND medical policies are submitted for review to external practicing physicians. Physicians who wish to participate in this process may contact Medical Policy at: PICPolicyMail@bcbsnd.com . Policies scheduled for upcoming review may be found on the Upcoming Reviews tab on this page.

All policies are reviewed by the Medical Policy Physician External Advisory Panel. This panel includes representation of various clinical specialties, at least one practicing physician who is independent and free of conflict relative to the plan, and at least one practicing physician who is an expert regarding care of elderly or disabled individuals.

Approval process

All policy drafts, including analyses of the scientific evidence and summaries of the external expert opinion are presented to the Medical and Behavioral Health Policy Governance for final approval. The Governance body consists of professional medical policy staff and a diverse group of physician medical directors from Idaho, Oregon, Utah and Washington, and other key stakeholders from teams involved in the review and application of medical policies.

Medical policy updates

Medical policies are re-evaluated and updated annually. Policies may be reviewed prior to their scheduled annual review date if new scientific evidence becomes available that would change the policy criteria.

Medical policy dissemination

Medical policies are published on-line and available to members, providers and the general public at bcbsnd.com/providers/policies-precertification/medical-policy/disclaimer. Significant policy changes are communicated through provider newsletters and are noted on-line at bcbsnd.com/providers/news-resources/healthcare-news.

Medical Policy

All medical policies are listed below by default, and you can browse by category or search by policy name, ID, keywords, or CPT/HCPCS codes.

Search medical policies

Displaying 0 of 0 results

Policy updates

BCBSND and its affiliated Plans use medical policies as guidelines for coverage decisions within the member’s written benefits. Below are summaries of recent changes to BCBSND's medical policies. The detailed policies are available online at bcbsnd.com/providers/policies-precertification/medical-policy/disclaimer. We have included the section and policy number for your convenience.

Last updated: August 1, 2026

Policy name

Summary of policy or change

Effective date

Section and policy number

Coding or implementation change

Pre-authorization change

Rhinoplasty

Rearranging criteria for nasal airway obstruction,
Updating to allow for physical examination techniques or advanced imaging,
Adding requirement of a positive Cottle maneuver.

December 1, 2026

Surgery #12.28

N/A

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

Adding initial assessment criteria.

November 1, 2026

Behavioral Health #18

N/A

Reduction Mammaplasty

Clarifying Policy Guidelines regarding referring provider documentation.

November 1, 2026

Surgery #60

N/A

Low-Level Laser Therapy

Making code edit changes for CPT codes 1011T and 97037 to align with implementation for other codes in the policy

October 1, 2026

Medicine #105

Changing edits on CPT codes 1011T and 97037 from prior authorization required to always investigational unless submitted with specific diagnosis codes C81.00-C88.9, K123.0, K123.1, K123.2, K123.3, K123.9, Z51.0, Z51.11, Z92.21, Z92.3. This will be to align with implementation for other codes in the policy.

Removing CPT codes 1011T, 97037 from the preauth website for this policy.
Codes will deny as investigational and be added to the workflow that will override the investigational edit, if one of the specific diagnosis codes C81.00-C88.9, K123.0, K123.1, K123.2, K123.3, K123.9, Z51.0, Z51.11, Z92.21, Z92.3. is billed.

Cochlear Implants

Removing criteria for enlarged vestibular apparatus

October 1, 2026

Surgery #08

N/A

Varicose Vein Treatment

Updating criteria for clarity.
Limiting coverage for phlebitis to thrombophlebitis

October 1, 2026

Surgery #104

Adding preauth edit to CPT codes 36476, 36479, 36483 for this policy.

Adding CPT codes 36476, 36479, 36483 to the preauth website for this policy.

Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Adding documentation requirements to criteria.

October 1, 2026

Surgery #107

N/A

Artificial Intervertebral Disc

Adding documentation requirements to criteria.

October 1, 2026

Surgery #127

N/A

Femoroacetabular Impingement Surgery

Adding documentation requirements to criteria.

October 1, 2026

Surgery #160

N/A

Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with Chronic Liver Disease

Removed the Enhanced Liver Fibrosis (ELF) test from the policy
Added the OWLiver test, which was moved from medical policy LAB77 - Investigational Gene Expression, Biomarker, and Multianalyte Testing.

September 1, 2026

Laboratory #47

Removed CPT code 81517 from this policy and removed investigational denial.
Added CPT 0344U to this policy and continue investigational denial.

N/A

Laboratory Tests for Organ Transplant Rejection

Reduced post-transplant timeframe from 6 months to 2 months for peripheral blood gene expression profiling (GEP) testing.

September 1, 2026

Laboratory #51

N/A

Investigational Gene Expression, Biomarker, and Multianalyte Testing

Removed the OWLiver test, which is now addressed in medical policy LAB47 - Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with Chronic Liver Disease.

September 1, 2026

Laboratory #77

Removed CPT code 0344U from this medical policy.

N/A

Mastectomy as a Treatment of Gynecomastia

Added medically necessary criteria for select indications.

September 1, 2026

Surgery #12.06

Changed edit on CPT code 19300 to remove the cosmetic denial and add prior authorization.

Added CPT code 19300 to the prior authorization website.

Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair

Updated photo documentation requirements.

August 1, 2026

Surgery #12.05

N/A

Cervical Spinal Fusion

New policy.

August 1, 2026

Surgery #244

Adding CPT codes: 22551, 22552, 22554, 22600, 22853, 22854, 22859 and will continue preauth edit.

Adding CPT codes: 22551, 22552, 22554, 22600, 22853, 22854, 22859 to the preauth website for this policy.

Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb

Updated policy title; policy was previously titled Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Updated policy scope to address microprocessor-powered orthoses of the upper limb

July 1, 2026

Allied Health #05

Adding the following codes and edits for all commercial health plan lines of business:
For HCPCS codes A9152, A9153 will change current denial edit to not medically necessary edit.
Change edit on HCPCS codes B4100, B4102, B4103, B4104, S9432, S9433 that currently have no clinical edit to add not medically necessary edit.
Change edit on HCPCS codes B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B9002, B9998, B4105, B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9434, S9435 that currently have no clinical edit to add a preauth edit.

Add HCPCS codes B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B9002, B9998, B4105, B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9434, S9435 to the preauth website for this policy.

Functional Neuromuscular Electrical Stimulation

Moved tonic motor activation to new medical policy Tonic Motor Activation (TOMAC) for Restless Legs Syndrome (DME #83.15)

July 1, 2026

Durable Medical Equipment #83.04

Moved HCPCS codes A4544, E0743 to new medical policy DME83.15 with no change to investigational edit.

N/A

Tonic Motor Activation (TOMAC) for Restless Legs Syndrome

New policy.

July 1, 2026

Durable Medical Equipment #83.15

Added HCPCS codes A4544, E0743 to this policy with no change to investigational edit.

N/A

Evaluating the Utility of Genetic Panels

Added two new investigational panels.

July 1, 2026

Genetic Testing #64

Added new Q3 CPT codes 0651U, 0653U to this policy with investigational edit.
Removed deleted Q3 CPT code 0029U and the investigational edit for this policy.

N/A

Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers

Clarified criteria to indicate only blood-based testing, not urine testing, may be considered medically necessary

July 1, 2026

Laboratory #46

Added new Q3 CPT codes 0631U with preauth edit, and 0640U, 0641U, 0642U, 0643U, 0646U, 0647U with investigational edit to this policy.

Add CPT code 0631U to the preauth website for this policy.

Investigational Gene Expression, Biomarker, and Multianalyte Testing

Added one investigational test to policy
Removed Lyme disease tests, which are now addressed in the new commercial medical policy Lyme Disease Testing (Laboratory #83)

July 1, 2026

Laboratory #77

Added new Q3 CPT code 0635U with investigational edit to this policy.
Moved CPT codes 0041U, 0042U, 0316U, 0580U, 0615U to new policy LAB83 with no change to investigational edit.

N/A

Lyme Disease Testing

New policy.

July 1, 2026

Laboratory #83

Added new Q3 CPT codes 0636U, 0637U, 0638U, 0639U with investigational edit to this new policy.
Added CPT codes 0041U, 0042U, 0316U, 0580U, 0615U to this new policy with no change to investigational edit.

N/A

New and Emerging Medical Technologies and Procedures

Added 14 new CPT codes in alignment with the 2026 Q3 code set update.

July 1, 2026

Medicine #149

Add new Q3 CPT codes 1027T, 1028T, 1029T, 1030T, 1031T, 1032T, 1033T, 1034T, 1035T, 1038T, 1039T, 1040T, 1041T, 1042T with investigational edit to this policy.
Delete 0465T from this policy and remove investigational edit.

N/A

Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products

Added criteria related to adequate circulation and infection control to lower extremity ulcer indications and HbA1c requirement for diabetic ulcers
Added complete wound history and treatment plan to the list of required documentation
Added new Q3 CPT and HCPCS codes
Added Kerecis Omega3 to potentially covered products for diabetic ulcers

July 1, 2026

Medicine #170

Add new Q3 CPT codes 1044T, 1045T, 1046T, 1047T, 1048T. 1049T with investigational edit to this policy.

N/A

Histotripsy for Tumor Treatment

Updated policy title; policy was previously titled Histotripsy for Hepatic or Renal Tumor Treatment
Expanded policy scope to include histotripsy for pancreatic tumors

July 1, 2026

Medicine #178

Add new Q3 CPT codes 1037T with investigational edit to this policy.

N/A

Spinal Cord and Dorsal Root Ganglion Stimulation

Added documentation requirements to criteria

July 1, 2026

Surgery #45

N/A

Lumbar Spinal Fusion

Added documentation requirements to criteria

July 1, 2026

Surgery #187

N/A

Genetic Testing for Hereditary Breast, Ovarian, Pancreatic and Prostate Cancer and Li-Fraumeni Syndrome

Changed title from Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome
Updated criteria to more accurately reflect policy scope

June 1, 2026

Genetic Testing #02

N/A

Updated policy title on the preauth website.

Measurement of Serum Antibodies to Selected Biologic Agents

Golimumab (Simponi) drug/antibody levels added to medically necessary criteria

June 1, 2026

Laboratory #65

N/A

Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver

Adding focal prostate cryoablation to policy as investigational

June 1, 2026

Surgery #132

Adding unlisted code 55899 and continue unlisted code review.

N/A

Analysis of Human DNA or RNA in Stool Samples as a Technique for Colorectal Cancer Screening

Title changed from Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
Removing Cologuard Plus.

May 1, 2026

Genetic Testing #12

Removed CPT code 0464U from the policy and changed from investigational denial to no clinical edit for this code.

N/A

Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products

No policy update, but changed edit on HCPCS code Q4160 from “always investigational” to “potentially investigational.”

May 1, 2026

Medicine #170

Changed edit on HCPCS code Q4160 from “always investigational” to “potentially investigational” and add to the preauth website for this policy.

Add HCPCS codes Q4160 to the preauth website for this policy.

Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb

Updated policy title; policy was previously titled Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Update policy scope to address microprocessor-powered orthoses of the upper limb

April 1, 2026

Durable Medical Equipment #80

Added new Q2 HCPCS codes A8005, A8006 with investigational edit.

N/A

Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes

Changing edit on CPT 81435 from investigational to add pre-authorization

April 1, 2026

Genetic Testing #06

For CPT code 81435, we are removing the investigational edit and adding preauth.

Adding CPT code 81435 to the preauth website for this policy.

Evaluating the Utility of Genetic Panels

Added five new investigational panels
Removed four panel tests

April 1, 2026

Genetic Testing #64

Added new Q2 CPT code 0628U with investigational edit.

N/A

Drug Testing for Substance Use and Pain Management

Changed two codes from medically necessary to not medically necessary.

April 1, 2026

Laboratory #68

Changing the edits on codes 0007U, 0227U from medically necessary to not medically necessary for this policy.

N/A

Investigational Gene Expression, Biomarker, and Multianalyte Testing

Added 13 investigational tests

April 1, 2026

Laboratory #77

Added new Q2 CPT codes 0615U, 0616U, 0617U, 0618U, 0619U, 0620U, 0621U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U with investigational edit.
Revised description on CPT code 0580U with no change to the edit.

N/A

Gender Affirming Interventions for Gender Dysphoria

Specified time frame for hormone therapy.

April 1, 2026

Medicine #153

N/A

Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products

Added new Q2 HCPCS codes
Added NuShield to potentially covered products for diabetic ulcers

April 1, 2026

Medicine #170

Added new Q2 HCPCS codes A2040, A2041, A2042, A2043, A2044, A2045, Q4418, Q4419, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4435, Q4436, Q4437, Q4438, Q4439, Q4440, with investigational edit.
Added new Q2 HCPCS codes G0681, G0682, G0683, G0684, with preauth edit.
Revised description on HCPCS codes A2014, A2037 with no change to the edit.

Add HCPCS codes G0681, G0682, G0683, G0684, to the preauth website for this policy.

Extracranial Carotid Angioplasty and Stenting and Embolic Protection Devices

Updated policy title; policy was previously titled Extracranial Carotid Angioplasty and Stenting
Added criteria for permanent common carotid embolic protection device

April 1, 2026

Surgery #93

Added new HCPCS code Q2010 with investigational edit.

N/A

Gastroesophageal Reflux Surgery

Clarified criteria for gastrojujenostomy.

April 1, 2026

Surgery #186

Added CPT code 43820 and continue preauth edit.

Add CPT code 43820 to the preauth website for this policy.

Annular Closure Devices

Adding code C9757.

April 1, 2026

Surgery #243

Adding HCPCS code C9757 to this policy with investigational edit.

N/A

Upcoming policy reviews

BCBSND medical policies are evidence-based and take into account the available scientific evidence published in peer-reviewed journals, as well as evidence-based clinical practice guidelines and specialty society statements. The process for BCBSND medical policy development is described in the Introduction tab on this page.

In addition, BCBSND values the experience and opinions of practicing physicians and other health care providers. Your feedback on our policies is welcome and is an important part of our annual policy review process.

You may provide feedback to us on the following policies by:

Responding to the email that directed you to this page. Please be sure to identify the policy you are providing comments on in your email response.
Contacting Medical Policy Staff. Please be sure to identify the policy in the policy name field, as well as your name, specialty and contact information. (Note: contact information only needs to be included if you do not regularly receive medical policy email notification from BCBSND.)

Policies scheduled for review, by month

Policy name

Section and policy number

Upcoming Review Month

Specialties

Hippotherapy

Allied Health #34

January

Neurology, Neurosurgery, Orthopedics, Physical Medicine, Primary Care

IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia

Genetic Testing #19

January

General Surgery, Genetics, Nephrology, Neurology, Neurosurgery, Pathology, Pediatric Surgery, Primary Care, Radiation Oncology

Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity

Genetic Testing #44

January

Genetics, Obstetrics and Gynecology

Genetic Testing for Statin-Induced Myopathy

Genetic Testing #50

January

Cardiology, Genetics

Diagnostic Genetic Testing for ?-Thalassemia

Genetic Testing #52

January

Genetics, Hematology Oncology

Genetic Testing for Primary Mitochondrial Disorders

Genetic Testing #54

January

Genetics, Neurology

Genetic Testing for the Diagnosis of Inherited Peripheral Neurophathies

Genetic Testing #66

January

Genetics, Neurology

Genetic Testing for Lactase Insufficiency

Genetic Testing #67

January

Gastroenterology, Genetics

Genetic Testing for Duchenne and Becker Muscular Dystrophy

Genetic Testing #69

January

Genetics, Neurology

Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification

Genetic Testing #70

January

Genetics, Oncology

Salivary Hormone Testing for Aging and Menopause

Laboratory #36

January

Obstetrics and Gynecology, Primary Care, Pulmonology

Folate Testing

Laboratory #79

January

General Surgery, Hematology Oncology, Infectious Disease, Naturopath, Oncology, Primary Care

Measurement of Exhaled Breath Condensates in the Diagnosis and Management of Other Respiratory Disorders

Medicine #108

January

Neurology, Neurosurgery, Orthopedics, Primary Care

Prolotherapy

Medicine #40

January

Neurology, Neurosurgery, Orthopedics, Primary Care

Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders

Radiology #38

January

Bariatric, Gastroenterology, Radiology

Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)

Surgery #190

January

Gastroenterology, General Surgery

Knee Surgeries

Surgery #229

January

Orthopedics

Small Bowel, Small Bowel/Liver, and Multivisceral Transplant

Transplant #09

January

Gastroenterology, Solid Organ Transplants

Placental and Umbilical Cord Blood as a Source of Stem Cells

Transplant #45.16

January

Hematology Oncology

Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

Transplant #45.25

January

Hematology Oncology

Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

Transplant #45.27

January

Hematology Oncology, Oncology

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

Transplant #45.28

January

Hematology Oncology

Augmentative Communication Devices and Systems

Durable Medical Equipment #52

February

Primary Care, Speech

Interferential Current Stimulation

Durable Medical Equipment #83.07

February

Anesthesiology, Chiropractic, Physical Medicine, Primary Care

Tumor Treatment Field Therapy (TTFT)

Durable Medical Equipment #85

February

Electrodiagnostics, Neurology, Neurosurgery, Oncology

Genetic Testing for Alzheimer's Disease

Genetic Testing #01

February

Genetics, Neurology, Neurosurgery, Primary Care, Oncology

Genetic Testing for Hereditary Breast, Ovarian, Pancreatic and Prostate Cancer and Li-Fraumeni Syndrome

Genetic Testing #02

February

Genetics, Hematology Oncology, Naturopath, Obstetrics and Gynecology, Oncology, Pathology, Primary Care

Genetic Testing for Cutaneous Malignant Melanoma

Genetic Testing #08

February

Dermatology, Genetics, Oncology, Primary Care

Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing

Genetic Testing #10

February

Genetics, Hematology Oncology, Pathology, Primary Care

Gene Expression-Based Assays for Cancers of Unknown Primary

Genetic Testing #15

February

Oncology

Genetic and Molecular Diagnostic Testing

Genetic Testing #20

February

Genetics

Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy

Genetic Testing #21

February

Genetics

Diagnostic Genetic Testing for FMR1 and AFF2 Variants (including Fragile X and Fragile XE Syndromes)

Genetic Testing #43

February

Genetics, Neurology, Obstetrics and Gynecology, Pediatrics

Genetic Testing for Myeloid Neoplasms and Leukemia

Genetic Testing #59

February

Genetics, Hematology Oncology, Oncology, Pathology, Primary Care

Serum Holotranscobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status

Laboratory #44

February

Bariatric, Endocrinology, Gastroenterology, Pathology, Primary Care

Maternal Serum Analysis for Risk of Adverse Obstetric Outcomes

Laboratory #75

February

Obstetrics and Gynecology, Primary Care

Non-Contact Ultrasound Treatments for Wounds

Medicine #131

February

General Surgery, Primary Care

Auricular Electrostimulation

Medicine #146

February

Anesthesiology, Chiropractic, Physical Medicine, Primary Care, Psychiatry

Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders

Medicine #148

February

Behavioral Health, Neurology, Neurosurgery, Primary Care, Psychiatry

Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products

Medicine #170

February

General Surgery, Oncology, Primary Care, Urology

Positional Magnetic Resonance Imaging (MRI)

Radiology #49

February

Neurosurgery, Orthopedics, Primary Care, Radiology

Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty

Surgery #118

February

Neurosurgery, Orthopedics, Radiology

Artificial Intervertebral Disc

Surgery #127

February

Neurosurgery, Orthopedics

Occipital Nerve Stimulation

Surgery #174

February

General Surgery, Neurology, Neurosurgery, Primary Care

Electromagnetic Navigation Bronchoscopy

Surgery #179

February

Pulmonology

Air Ambulance Transport

Utilization Management #13

February

Primary Care

External Trigeminal Nerve Stimulation for the Treatment of Attention Deficit Hyperactivity Disorder

Durable Medical Equipment #83.14

March

Behavioral Health, Primary Care, Psychiatry

Upper Extremity Rehabilitation System with Brain-Computer Interface

Durable Medical Equipment #94

March

Rehabilitation Medicine

Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar

Durable Medical Equipment #97

March

Chiropractic, General Surgery, Orthopedics, Primary Care

Mechanical Residual Limb Volume Management System for Upper Extremity Prostheses

Durable Medical Equipment #98

March

Primary Care

Preimplantation Genetic Testing of Embryos

Genetic Testing #18

March

Genetics, Infertility, Obstetrics and Gynecology

Whole Exome and Whole Genome Sequencing

Genetic Testing #76

March

Behavioral Health, Cardiology, Electrodiagnostics, Gastroenterology, Genetics, Hematology Oncology, Naturopath, Nephrology, Neurology, Obstetrics and Gynecology, Oncology, Pediatrics, Primary Care

ClonoSEQ® Testing for the Assessment of Measurable Residual Disease (MRD)

Genetic Testing #88

March

Genetics, Hematology Oncology, Oncology

In Vitro Chemoresistance and Chemosensitivity Assays

Laboratory #06

March

Hematology Oncology, Pathology

COVID-19 Testing

Laboratory #74

March

Infectious Disease, Nephrology, Primary Care, Pulmonology

Testosterone Testing

Laboratory #81

March

Endocrinology, Primary Care, Urology

Immunological Cellular Therapies and Gene Therapies

Medicine #42

March

Hematology Oncology, Oncology

Vertebral Axial Decompression

Medicine #45

March

Chiropractic, Neurosurgery, Orthopedics, Physical Medicine, Primary Care

Screening for Vertebral Fracture or Fracture Risk with Dual X-ray Absorptiometry (DXA)

Radiology #48

March

Endocrinology, Orthopedics, Osteoporosis, Primary Care, Radiology

Cochlear Implant

Surgery #08

March

ENT, Pediatric Surgery, Pediatrics

Varicose Vein Treatment

Surgery #104

March

General Surgery, Primary Care, Radiology, SUR104 Only

Transcutaneous Bone-Conduction and Bone-Anchored Hearing Aids

Surgery #121

March

ENT

Surgical Treatments for Hyperhidrosis

Surgery #165

March

Dermatology, General Surgery, Plastic Surgery, Primary Care

Bronchial Valves

Surgery #184

March

Pulmonology

Transcatheter Aortic Valve Implantation for Aortic Stenosis

Surgery #201

March

Cardiology

Balloon Dilation of the Eustachian Tube

Surgery #206

March

Allergy, ENT

Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis

Surgery #230

March

Urology

Cervical Spinal Fusion

Surgery #244

March

Neurosurgery, Orthopedics

Deep Brain Stimulation

Surgery #84

March

Neurology, Neurosurgery, Pediatrics, Physical Medicine

Heart Transplant

Transplant #02

March

Cardiology, General Surgery

Heart-Lung Transplant

Transplant #03

March

Cardiology, General Surgery, Pulmonology

Liver Transplant

Transplant #05

March

Gastroenterology, Solid Organ Transplants

Lung and Lobar Lung Transplant

Transplant #08

March

Cardiology, Pulmonology

Islet Transplantation

Transplant #13

March

Endocrinology, Gastroenterology

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorders

Behavioral Health #18

April

Behavioral Health, Pediatrics, Psychiatry

Patient Lifts and Seat Lifts

Durable Medical Equipment #23

April

Orthopedics, Physical Medicine, Primary Care

Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation)

Durable Medical Equipment #83.12

April

Orthopedics

Gene Expression Profiling for Melanoma

Genetic Testing #29

April

Genetics, Infertility, Obstetrics and Gynecology

Genetic Testing for CADASIL Syndrome

Genetic Testing #51

April

Genetics, Neurology, Primary Care

Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder, or Congenital Anomalies

Genetic Testing #58

April

Genetics, Pediatrics, Primary Care

Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities

Genetic Testing #78

April

Genetics, Obstetrics and Gynecology

Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss

Genetic Testing #79

April

Genetics, Obstetrics and Gynecology

Expanded Molecular Testing of Cancers to Select Targeted Therapies

Genetic Testing #83

April

Genetics, Hematology Oncology, Oncology

Measurement of Serum Antibodies to Selected Biologic Agents

Laboratory #65

April

Gastroenterology, Primary Care, Rheumatology

Signal-Averaged Electrocardiography (SAECG)

Medicine #21

April

Cardiology

Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting

Medicine #33

April

Cardiology, Primary Care

Histotripsy for Tumor Treatment

Medicine #178

April

General Surgery, Oncology

Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Surgery #107

April

General Surgery, Neurology, Radiology

Gastric Electrical Stimulation

Surgery #111

April

Bariatric, Endocrinology, Gastroenterology

Spinal Cord and Dorsal Root Ganglion Stimulation

Surgery #45

April

Cardiology, Neurology, Neurosurgery, Physical Medicine

Vagus Nerve Stimulation

Surgery #74

April

Neurology, Neurosurgery, Primary Care, Psychiatry

Hematopoietic Cell Transplantation for Autoimmune Diseases

Transplant #45.32

April

Hematology Oncology, Oncology, Radiology

Hematopoietic Cell Transplantation for Light-Chain (AL) Amyloidosis or Waldenström Macroglobulinemia

Transplant #45.40

April

Hematology Oncology, Oncology, Radiology

Prefabricated Oral Appliances for Obstructive Sleep Apnea

Allied Health #36

May

Oral Surgeons, Sleep Physicians

Substance Use Disorders

Behavioral Health #35

May

Behavioral Health, Psychiatry

Mental Health and Eating Disorders

Behavioral Health #36

May

Behavioral Health, Psychiatry

Cooling Devices Used in the Home Setting

Durable Medical Equipment #07

May

Orthopedics, Physical Medicine, Primary Care

Single-nucleotide Variants (SNVs) to Predict Risk of NonFamilial Breast Cancer

Genetic Testing #23

May

Genetics, Oncology

Genetic Testing for Alpha-1 Antitrypsin Deficiency

Genetic Testing #61

May

Genetics, Primary Care, Pulmonology

Genotyping for 9p21 Single Nucleotide Variants to Predict Risk of Cardiovascular Disease or Aneurysm

Genetic Testing #62

May

Cardiology, Genetics

Genetic Testing for PTEN Hamartoma Tumor Syndrome

Genetic Testing #63

May

Genetics, Oncology

Serologic Genetic and Molecular Screening for Colorectal Cancer

Genetic Testing #86

May

Gastroenterology, Primary Care

Multianalyte Assays with Algorithmic Analyses for the Evaluation and Monitoring of Patients with Chronic Liver Disease

Laboratory #47

May

Gastroenterology, Primary Care

Laboratory Tests for Organ Transplant Rejection

Laboratory #51

May

Cardiology, Solid Organ Transplants

Measurement of Lipoprotein-Associated Phospholipase A2 Lp-PLA2) in the Assessment of Cardiovascular Risk

Laboratory #63

May

Cardiology, Primary Care

Lyme Disease Testing

Laboratory #83

May

Infectious Disease, Primary Care

Sphenopalatine Ganglion Block for Headache and Pain

Medicine #160

May

Anesthesiology - Pain Management, ENT, Primary Care

Hyperoxemic Reperfusion Thearpy

Medicine #173

May

Cardiology

Quantitative Sensory Testing

Medicine #91

May

Anesthesiology, Anesthesiology - Pain Management, Chiropractic, Neurology, Orthopedics, Physical Medicine, Primary Care

Cosmetic and Reconstructive Procedures

Surgery #12

May

Plastic Surgery, Primary Care

Panniculectomy

Surgery #12.01

May

Plastic Surgery, Primary Care

Pectus Excavatum and Carinatum Treatment

Surgery #12.02

May

Plastic Surgery, Primary Care

Anterior Abdominal Wall (Including Incisional) Hernia Repair

Surgery #12.03

May

Plastic Surgery, Primary Care

Dermabrasion or Microdermabrasion

Surgery #12.04

May

Plastic Surgery, Primary Care

Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair

Surgery #12.05

May

Plastic Surgery, Primary Care

Mastectomy as a Treatment of Gynecomastia

Surgery #12.06

May

Plastic Surgery, Primary Care

Rhinoplasty

Surgery #12.28

May

Plastic Surgery, Primary Care

Laser Treatment for Port Wine Stains

Surgery #12.34

May

Plastic Surgery, Primary Care

Chemical Peels

Surgery #12.50

May

Plastic Surgery, Primary Care

Dynamic Stabilization of the Spine

Surgery #143

May

Neurosurgery, Radiology

Interspinous and Interlaminar Stabilization and Distraction Devices (Spacers)

Surgery #155

May

Neurosurgery, Orthopedics

Percutaneous Axial Lumbosacral Interbody Fusion (LIF)

Surgery #157

May

General Surgery, Neurosurgery, Orthopedics

Vertical Expandable Prosthetic Titanium Rib

Surgery #159

May

Orthopedics, Pediatric Surgery, Pediatrics

Plugs for Enteric and Anorectal Fistula Repair

Surgery #175

May

Gastroenterology, General Surgery, Obstetrics and Gynecology

Retinal Prosthesis

Surgery #194

May

Ophthalmology

Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation

Surgery #205

May

Neurology, Neurosurgery, Physical Medicine

Focal Laser Ablation of Prostate Cancer

Surgery #222

May

General Surgery, Oncology, Primary Care, Urology

Subacromial Balloon Placement

Surgery #226

May

Orthopedics, Rheumatology

Surgical Treatments for Glaucoma

Surgery #227

May

Ophthalmology

Long-Term Sub-Scalp Electroencephalography Monitoring Systems

Surgery #239

May

Neurology

Percutaneous Laser Ablation of Benign and Malignant Breast Tumors

Surgery #240

May

Oncology, Radiation Oncology, Radiology

Uterus Transplant

Transplant #19

May

Obstetrics and Gynecology

Enteral and Oral Nutrition in the Home Setting

Allied Health #05

June

Gastroenterology, Pediatrics, Primary Care

Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb

Durable Medical Equipment #80

June

Orthopedics, Physical Medicine, Primary Care

Bioimpedance Devices for Detection and Management of Lymphedema

Durable Medical Equipment #82

June

General Surgery, Orthopedics, Physical Medicine, Primary Care

Electrical Stimulation for the Treatment of Wounds

Durable Medical Equipment #83.09

June

Dermatology, General Surgery, Physical Medicine, Primary Care

Electrical Stimulation for the Treatment of Arthritis

Durable Medical Equipment #83.10

June

Orthopedics, Primary Care, Rheumatology

Tonic Motor Activation (TOMAC) for Restless Legs Syndrome

Durable Medical Equipment #83.15

June

Neurology, Neurosurgery, Orthopedics, Physical Medicine, Primary Care

Fetal Red Blood Cell Antigen Genotyping Using Maternal Plasma

Genetic Testing #74

June

Obstetrics and Gynecology

Genetic Testing for Heritable Disorders of Connective Tissue

Genetic Testing #77

June

Cardiology, Dentistry, Dermatology, Gastroenterology, Genetics, Obstetrics and Gynecology, Pediatrics

Allergy and Sensitivity Tests of Uncertain Efficacy

Laboratory #01

June

Allergy, ENT

Biochemical and Cellular Markers of Alzheimer's Disease

Laboratory #22

June

Neurology, Primary Care

Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover

Laboratory #23

June

Endocrinology, Orthopedics, Primary Care

Multi-biomarker Disease Activity Blood Test for Rheumatoid Arthritis

Laboratory #67

June

Rheumatology

Low-Level Laser Therapy

Medicine #105

June

Neurology, Neurosurgery, Orthopedics, Physical Medicine, Primary Care, Rheumatology

Optical Coherence Tomography (OCT) of the Anterior Eye Segment

Medicine #133

June

Ophthalmology

Charged-Particle (Proton) Radiotherapy

Medicine #49

June

Hematology Oncology, Radiation Oncology

Magnetic Resonance Spectroscopy

Radiology #27

June

Gastroenterology, Radiology

Extravascular (Substernal) Implantable Cardioverter-Defibrillator

Surgery #17

June

Cardiology

Sacroiliac Joint Fusion

Surgery #193

June

Anesthesiology - Pain Management, Orthopedics, Rheumatology

Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia

Surgery #196

June

Gastroenterology, General Surgery

Phrenic Nerve Stimulation for Central Sleep Apnea

Surgery #212

June

ENT, Pulmonology, Sleep Physicians

Hypoglossal Nerve Stimulation

Surgery #215

June

ENT, Pulmonology, Sleep Physicians

Surgical Treatments for Lymphedema and Lipedema

Surgery #220

June

Bariatric, General Surgery, Plastic Surgery

Transcatheter Heart Valve Procedures for Mitral or Tricuspid Valve Disorders

Surgery #221

June

Cardiology, General Surgery

Radiofrequency and Ultrasound Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension

Surgery #235

June

Nephrology, Primary Care

Dental and Orthodontic Treatment for Craniofacial Anomalies

Allied Health #33

July

Dentistry, ENT, Oral Surgeons, Pediatric Surgery, Pediatrics, Plastic Surgery

Definitive Lower Limb Prostheses

Durable Medical Equipment #18

July

General Surgery, Physiatry, Primary Care, Rehabilitation Medicine

Power Wheelchairs: Group 2 and Group 3

Durable Medical Equipment #37

July

Physical Medicine, Primary Care

Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment

Durable Medical Equipment #75

July

Endocrinology, Neurology, Orthopedics, Pediatrics, Physical Medicine, Primary Care, Pulmonology, Rheumatology, Sleep Physicians

Noninvasive Ventilators in the Home Setting

Durable Medical Equipment #87

July

Physiatry, Pulmonology

BRAF Genetic Testing To Select Melanoma or Glioma Patients for Targeted Therapy

Genetic Testing #41

July

Hematology Oncology

Evaluating the Utility of Genetic Panels

Genetic Testing #64

July

Genetics, Naturopath, Obstetrics and Gynecology, Oncology, Primary Care, Psychiatry

Genetic Testing for Rett Syndrome

Genetic Testing #68

July

Genetics, Neurology

Genetic Testing for Macular Degeneration

Genetic Testing #75

July

Genetics, Ophthalmology

Identification of Microorganisms Using Nucleic Acid Probes

Genetic Testing #85

July

Gastroenterology, Infectious Disease, Obstetrics and Gynecology, Primary Care

Confocal Laser Endomicroscopy

Medicine #151

July

Gastroenterology, Oncology

Skin Lesion Imaging and Spectroscopy

Medicine #174

July

Dermatology

Whole Body CT Screening

Radiology #40

July

Radiology

Whole Body Dual X-ray Absorptiometry (DXA) to Determine Body Composition

Radiology #41

July

Infectious Disease, Primary Care, Radiology

Nerve Graft with Radical Prostatectomy

Surgery #117

July

Urology

Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty™)

Surgery #131

July

Neurosurgery, Orthopedics, Radiology

Automated Percutaneous and Percutaneous Endoscopic Discectomy

Surgery #145

July

Neurosurgery, Orthopedics, Radiology

Surgical Ventricular Restoration

Surgery #149

July

Cardiology, General Surgery

Total Facet Arthroplasty

Surgery #171

July

Neurosurgery, Orthopedics

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites

Surgery #213

July

Neurosurgery, Oncology, Radiation Oncology

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

Surgery #214

July

Neurosurgery, Oncology, Radiation Oncology

Percutaneous Neuromodulation Therapy (PNT) and Percutaneous Electrical Nerve Stimulation (PENS)

Surgery #44

July

Hematology Oncology, Radiology

Reduction Mammaplasty

Surgery #60

July

General Surgery, Obstetrics and Gynecology, Oncology, Plastic Surgery

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Surgery #87

July

Orthopedics, Podiatry, Rehabilitation Medicine

Biofeedback

Allied Health #32

August

Cardiology, Gastroenterology, Neurology, Obstetrics and Gynecology, Ophthalmology, Pediatrics, Physical Medicine, Primary Care, Psychiatry, Pulmonology, Urology

Electrical Bone Growth Stimulators (Osteogenic Stimulation)

Durable Medical Equipment #83.11

August

Neurosurgery, Orthopedics, Podiatry, Primary Care

Powered Exoskeleton for Ambulation and Rehabilitation

Durable Medical Equipment #89

August

Rehabilitation Medicine

Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening

Genetic Testing #12

August

Genetics, Oncology

Genetic Testing for Diagnosis and Management of Behavioral Health Conditions

Genetic Testing #53

August

Behavioral Health, Genetics, Psychiatry

Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers

Laboratory #46

August

Hematology Oncology, Obstetrics and Gynecology, Primary Care

Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance

Laboratory #72

August

Hematology Oncology, Urology

Molecular Testing in the Management of Pulmonary Nodules

Laboratory #73

August

Hematology Oncology, Pulmonology

Multianalyte and Gene Expression Assays for Predicting Recurrence in Colon Cancer

Laboratory #76

August

Hematology Oncology, Oncology

Circulating Tumor-Tissue Modified Viral DNA Testing for Cancer Management

Laboratory #82

August

Gastroenterology, Hematology Oncology, Infectious Disease, ENT, Oncology, Pathology, Radiation Oncology

Whole Body Hyperthermia

Medicine #15

August

Hematology Oncology, Radiology

Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS), and High Intensity Focused Ultrasound (HIFU) Ablation, and Transurethral Ultrasound Ablation (TULSA)

Surgery #139

August

Hematology Oncology, Neurosurgery, Obstetrics and Gynecology, Primary Care, Urology

Balloon Ostial Dilation for Treatment of Sinusitis

Surgery #153

August

ENT, Primary Care

Implantable Sinus Devices for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinonasal Polyposis

Surgery #198

August

ENT, Primary Care

Radiofrequency Ablation and Injection of Sacroiliac Joint Nerves

Surgery #231

August

Orthopedics

Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

Surgery #40

August

General Surgery, Plastic Surgery

Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome

Transplant #45.22

August

Hematology Oncology, Oncology

Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Transplant #45.24

August

Hematology Oncology, Oncology

Hematopoietic Cell Transplantation for Hodgkin Lymphoma

Transplant #45.30

August

Hematology Oncology, Oncology

Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia

Transplant #45.31

August

Hematology Oncology, Oncology

Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

Transplant #45.33

August

Hematology Oncology, Oncology

Hematopoietic Cell Transplantation for Solid Tumors of Childhood

Transplant #45.37

August

Hematology Oncology, Oncology

Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors

Transplant #45.38

August

Hematology Oncology, Oncology, Radiology

Powered and Microprocessor-Controlled Knee and Ankle-Foot Prostheses and Microprocessor-Controlled Knee-Ankle-Foot Orthoses

Durable Medical Equipment #81

September

Orthopedics, Physical Medicine, Primary Care

Oxygen Concentrators

Durable Medical Equipment #91

September

Cardiology, ENT, Primary Care, Pulmonology

Lower Extremity Sensory Prostheses

Durable Medical Equipment #95

September

Primary Care

Amplitude-Modulated Radiofrequency Electromagnetic Fields (AM RF-EMF) for Cancer Treatment

Durable Medical Equipment #96

September

Gastroenterology, Oncology

Gene-Based Tests for Screening, Detection, and Management of Prostate or Bladder Cancer

Genetic Testing #17

September

Genetics, Urology

Reproductive Carrier Screening for Genetic Diseases

Genetic Testing #81

September

Genetics, Obstetrics and Gynecology

Genetic Testing for Neurofibromatosis Type 1 or 2

Genetic Testing #84

September

Genetics, Neurology, Neurosurgery, Oncology, Ophthalmology, Orthopedics, Pediatrics, Primary Care

Hyperbaric Oxygen Therapy

Medicine #14

September

Anesthesiology - Pain Management, Cardiology, Dermatology, General Surgery, Hematology Oncology, Infertility, Naturopath, Neurology, Neurosurgery, Oncology, Ophthalmology, Oral Surgeons, Orthopedics, Pediatrics, Primary Care, Pulmonology, Radiology, Rheumatology

Gender Affirming Interventions for Gender Dysphoria

Medicine #153

September

Behavioral Health, General Surgery, Obstetrics and Gynecology, Plastic Surgery, Primary Care, Psychiatry, Urology

Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid

Medicine #164

September

Hematology Oncology, Oncology, Radiation Oncology

Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities

Medicine #165

September

Hematology Oncology, Oncology, Radiation Oncology

Intensity Modulated Radiotherapy (IMRT) for Breast Cancer

Medicine #166

September

Oncology, Radiation Oncology

Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk

Medicine #167

September

Oncology, Radiation Oncology

Digital Therapeutic Products

Medicine #175

September

Anesthesiology - Pain Management, Behavioral Health, Pediatrics, Primary Care, Psychiatry

Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder

Medicine #175.01

September

Anesthesiology - Pain Management, Behavioral Health, Pediatrics, Primary Care, Psychiatry

Digital Therapeutic Products for Substance Use Disorders

Medicine #175.02

September

Anesthesiology - Pain Management, Behavioral Health, Primary Care, Psychiatry

Digital Therapeutic Products for Chronic Low Back Pain

Medicine #175.03

September

Anesthesiology - Pain Management, Behavioral Health, Orthopedics, Primary Care

Digital Therapeutic Products for Amblyopia

Medicine #175.04

September

Ophthalmology

Digital Therapeutic Products for Gait Training

Medicine #175.06

September

Neurology, Physical Medicine

Neurofeedback

Medicine #65

September

Neurology, Pediatrics, Psychiatry

Extracorporeal Shock Wave Therapy (ESWT)

Medicine #90

September

Orthopedics, Podiatry

Opto-acoustic Imaging of the Breast

Radiology #60

September

Radiation Oncology

Ultrasound Guidance for Facet Joint Injection

Surgery #135

September

Anesthesiology - Pain Management, Chiropractic, Orthopedics, Physical Medicine

Subtalar Arthroereisis

Surgery #144

September

Orthopedics, Podiatry

Bronchial Thermoplasty

Surgery #178

September

Pulmonology

Baroreflex Stimulation Devices

Surgery #183

September

Cardiology, Neurology, Primary Care

Intracardiac Ischemia Monitoring

Surgery #208

September

Cardiology, Primary Care

Dual Chamber Leadless Cardiac Pacemakers

Surgery #217

September

Cardiology

Ablation of Peripheral Nerves to Treat Pain

Surgery #236

September

Anesthesiology - Pain Management, Neurosurgery, Physiatry, Radiology

Extracranial Carotid Angioplasty and Stenting

Surgery #93

September

Cardiology, Neurology, Primary Care, Radiology

Lysis of Epidural Adhesions

Surgery #94

September

Neurology, Neurosurgery, Orthopedics, Primary Care

Pancreas Transplant

Transplant #06

September

Endocrinology, Solid Organ Transplants

Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant

Transplant #45.03

September

Oncology

Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma

Transplant #45.35

September

Hematology Oncology, Oncology

Pelvic Floor Stimulation or Mechanotransduction as a Treatment of Urinary and Fecal Incontinence

Allied Health #04

October

Obstetrics and Gynecology, Primary Care, Urology

Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems

Durable Medical Equipment #77

October

Endocrinology, General Surgery, Pediatrics, Primary Care

Electromagnetic Therapy

Durable Medical Equipment #83.13

October

Orthopedics, Primary Care, Rheumatology

Postsurgical Home Use of Limb Compression Devices

Durable Medical Equipment #90

October

General Surgery, Orthopedics, Physical Medicine, Primary Care

Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes

Genetic Testing #06

October

Genetics, Oncology

Genetic Testing for Epilepsy

Genetic Testing #80

October

Neurology, Pediatrics

Vitamin D Testing

Laboratory #52

October

Endocrinology, Naturopath, Osteoporosis, Primary Care, Vitamin D Expertise

Protein Biomarkers and Multi-analyte Biomarker Tests for Screening, Detection, and/or Management of Prostate Cancer

Laboratory #69

October

Genetics, Oncology, Radiation Oncology, Urology

Screening Laboratory Testing

Laboratory #80

October

Endocrinology, Genetics, Primary Care, Rheumatology

Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia

Medicine #100

October

Cardiology

In Vivo Analysis of Colorectal Lesions

Medicine #104

October

Gastroenterology, Primary Care

Ingestible pH and Pressure Capsule

Medicine #117

October

Gastroenterology, Primary Care

Sublingual Immunotherapy as a Technique of Allergen Specific Therapy

Medicine #121

October

Allergy, ENT, Naturopath

Actigraphy

Medicine #125

October

ENT, Neurology, Pulmonology, Sleep Physicians

Cell Therapy for Peripheral Arterial Disease

Medicine #141

October

Dermatology, General Surgery, Orthopedics, Primary Care

Orthopedic Applications of Stem Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow

Medicine #142

October

Orthopedics

Transcutaneous Electrical Modulation Pain Reprocessing

Medicine #143

October

Anesthesiology - Pain Management, Hematology Oncology, Naturopath, Neurology, Neurosurgery, Oncology, Orthopedics, Physical Medicine, Primary Care, Rheumatology

Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder

Medicine #175.05

October

Behavioral Health, Primary Care

Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions

Medicine #77

October

Dermatology, General Surgery, Neurosurgery, Ophthalmology, Oral Surgeons, Orthopedics, Plastic Surgery, Podiatry, Primary Care

Endometrial Ablation

Surgery #01

October

Obstetrics and Gynecology

Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast

Surgery #182

October

Plastic Surgery

Lumbar Spinal Fusion

Surgery #187

October

Neurosurgery, Orthopedics

Ablation for the Treatment of Chronic Rhinitis

Surgery #224

October

Allergy, ENT

Bariatric Surgery

Surgery #58

October

Bariatric, General Surgery, Primary Care

Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

Transplant #45.36

October

Hematology Oncology, Oncology, Radiology

Administrative Guidelines to Determine Dental vs Medical Services

Allied Health #35

November

Dentistry, Primary Care

Galvanic Stimulation

Durable Medical Equipment #83.01

November

Neurology, Physical Medicine, Primary Care

H-wave Stimulation

Durable Medical Equipment #83.02

November

Neurology, Physical Medicine, Primary Care

Microcurrent Stimulation (MENS)

Durable Medical Equipment #83.03

November

Neurology, Physical Medicine, Primary Care

Functional Neuromuscular Electrical Stimulation

Durable Medical Equipment #83.04

November

Neurology, Neurosurgery, Orthopedics, Physical Medicine, Primary Care

Threshold Electrical Stimulation as a Treatment of Motor Disorders

Durable Medical Equipment #83.05

November

Neurology, Pediatrics, Physical Medicine

Cranial Electrostimulation Therapy (CES)

Durable Medical Equipment #83.06

November

Anesthesiology, Chiropractic, Physical Medicine, Primary Care, Psychiatry

General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)

Durable Medical Equipment #88

November

Orthopedics, Physical Medicine, Primary Care

Genetic Testing for Familial Hypercholesterolemia

Genetic Testing #11

November

Cardiology

Molecular Testing for Interstitial Lung Disease

Genetic Testing #55

November

Genetics, Hematology Oncology

Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)

Genetic Testing #56

November

Genetics, Hematology Oncology

Genetic Testing for Methionine Metabolism Enzymes, including MTHFR

Genetic Testing #65

November

Genetics, Naturopath, Primary Care

Analysis of Proteomic and Metabolomic Patterns for Cancer Detection, Risk, Prognosis, or Treatment Selection

Laboratory #41

November

Hematology Oncology, Pathology

Invetigational Gene Expression, Biomarker, and Multianalyte Testing

Laboratory #77

November

Behavioral Health, Dermatology, Oncology

Manipulation Under Anesthesia

Medicine #130

November

Anesthesiology, Chiropractic, Orthopedics, Physical Medicine, Primary Care

New and Emerging Medical Technologies and Procedures

Medicine #149

November

Gastroenterology, General Surgery, Ophthalmology, Pediatrics, Primary Care, Radiology

Coverage of Treatments Provided in a Clinical Trial

Medicine #150

November

Primary Care

Vestibular Evoked Myogenic Potential Testing

Medicine #169

November

ENT, Neurology

Periurethral Transperineal Adjustable Balloon Continence Device

Medicine #176

November

General Surgery, Urology

Dry Needling

Medicine #39

November

Chiropractic, Primary Care

Targeted Phototherapy for the Treatment of Psoriasis

Medicine #98

November

General Surgery, Hematology Oncology, Obstetrics and Gynecology, Primary Care

Computed Tomography to Detect Coronary Artery Calcifications

Radiology #06

November

Cardiology, Radiology

Thermography

Radiology #17

November

Chiropractic, Neurology, Neurosurgery, Obstetrics and Gynecology, Orthopedics, Primary Care, Radiology

Cone Beam Computed Tomography of the Breast

Radiology #59

November

Obstetrics and Gynecology, Oncology, Radiation Oncology

Artificial Intelligence Augmented Analysis of Atherosclerotic Plaque from Computed Tomography Scan

Radiology #61

November

Cardiology, Electrodiagnostics

Percutaneous Angioplasty and Stenting of Veins

Surgery #109

November

General Surgery, Hematology Oncology, Neurology, Radiology

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

Surgery #110

November

Bariatric, Endocrinology, Gastroenterology

Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver

Surgery #132

November

Gastroenterology, General Surgery, Hematology Oncology, Oncology, Radiation Oncology, Radiology, Urology

Subcutaneous Tibial Nerve Stimulation

Surgery #154

November

Obstetrics and Gynecology, Primary Care, Urology

Femoroacetabular Impingement Surgery

Surgery #160

November

Orthopedics

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome

Surgery #166

November

ENT, Pulmonology, Sleep Physicians

Microwave Tumor Ablation

Surgery #189

November

General Surgery, Oncology, Pediatric Surgery, Radiation Oncology

Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

Surgery #195

November

Cardiology, Neurology, Neurosurgery, Primary Care

Ablation of Primary and Metastatic Liver Tumors

Surgery #204

November

General Surgery, Hematology Oncology, Oncology, Radiation Oncology, Urology

Minimally Invasive Treatments of Nasal Valve Collapse or Obstruction

Surgery #209

November

ENT, General Surgery

Responsive Neurostimulation

Surgery #216

November

Neurology, Pediatrics

Intraosseous Radiofrequency Ablation of the Basivertebral Nerve

Surgery #225

November

General Surgery, Neurosurgery, Orthopedics

Vertebral Body Tethering and Stapling

Surgery #232

November

General Surgery, Orthopedics

Ultrasound-Guided Percutaneous Needle Release for the Treatment of Carpal Tunnel Syndrome

Surgery #241

November

General Surgery, Orthopedics

Irreversible Electroporation

Surgery #242

November

Hematology Oncology, Oncology, Radiation Oncology

Annular Closure Devices

Surgery #243

November

Neurosurgery, Orthopedics

Radiofrequency Ablation (RFA) of Tumors Other than Liver

Surgery #92

November

Gastroenterology, General Surgery, Hematology Oncology, Nephrology, Obstetrics and Gynecology, Orthopedics

Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphomas

Transplant #45.23

November

Hematology Oncology, Oncology, Radiology

Negative Pressure Wound Therapy in the Outpatient Setting

Durable Medical Equipment #42

December

General Surgery, Pediatric Surgery, Primary Care

Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease

Genetic Testing #05

December

Cardiology, Genetics, Primary Care

KRAS, NRAS, and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer

Genetic Testing #13

December

Genetics, Oncology

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Breast Cancer Prognosis

Genetic Testing #42

December

Genetics, Hematology Oncology, Obstetrics and Gynecology, Oncology, Primary Care

Placental Rapid Immunoassay for Detection of Fetal Membrane Rupture

Laboratory #57

December

Obstetrics and Gynecology, Primary Care

Multimarker and Proteomics-based Serum Testing Related to Ovarian Cancer

Laboratory #60

December

General Surgery, Hematology Oncology, Obstetrics and Gynecology, Pathology

Drug Testing for Substance Use and Pain Management

Laboratory #68

December

Behavioral Health, Primary Care, Psychiatry

Biomarkers for Cardiovascular Disease

Laboratory #78

December

Cardiology, Primary Care

Automated Point-of-Care Nerve Conduction Studies

Medicine #128

December

Neurology, Neurosurgery, Primary Care

Ultrasonographic Measurement of Carotid Artery Intima-Media Thickness as an Assessment of Atherosclerosis

Radiology #37

December

Cardiology, Primary Care, Radiology

Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction

Surgery #134

December

Gastroenterology, Obstetrics and Gynecology, Primary Care, Urology

Orthognathic Surgery

Surgery #137

December

Dentistry, Oral Surgeons, Sleep Physicians

Pulsed Radiofrequency for Chronic Spinal Pain

Surgery #156

December

Neurology, Neurosurgery, Radiology

Interspinous Fixation (Fusion) Devices

Surgery #172

December

Neurosurgery, Orthopedics

Image-Guided Minimally Invasive Decompression (IG-MSD) for Spinal Stenosis

Surgery #176

December

Neurosurgery, Orthopedics

Gastroesophageal Reflux Surgery

Surgery #186

December

Gastroenterology, General Surgery, Pulmonology

Benign Prostatic Hyperplasia Surgical Treatments

Surgery #210

December

Urology

Transanal Hemorrhoidal Dearterialization

Surgery #219

December

Gastroenterology

Shoulder Surgeries

Surgery #228

December

Orthopedics

Intravascular Lithotripsy

Surgery #233

December

Cardiology

Ventricular Assist Devices and Total Artificial Hearts

Surgery #52

December

Cardiology

Vendor communications

All requests and inquiries concerning BCBSND medical policies that are related to medical devices and technologies must be directed to:

Medical Policy
PICPolicyMail@bcbsnd.com

Please do not contact individual BCBSND medical directors or medical policy clinicians.

When submitting data on a new or existing medical technology, please send an email to Medical Policy with the information below:

A subject line that states the type of technology (existing or new) and the specific technology name
A detailed description of the request and desired outcome. Please be as specific as possible and include copies of relevant, published, peer-reviewed studies.
Completion of the Medical Device/Technology Questionnaire, if applicable

At this time, meetings are not routinely scheduled. If a meeting is required to further discuss the submitted evidence, BCBSND will contact the vendor representative.

Note: Meeting requests to discuss utilization management or case management programs must be emailed to: PICPolicyMail@bcbsnd.com. Please include as much detail as possible concerning the proposed agenda.

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121