The list below is a standard precertification list. Some benefit plans have variations to the list.

• Air ambulance (non-emergent);
• Artificial intervertebral disc;
• Assisted reproductive technology for GIFT, ZIFT, ICSI and IVF;
• Autologous chondrocyte implantation;
• Bariatric surgery for morbid obesity;
• Behavioral Modification Intervention for Autism Spectrum Disorder (Including Applied Behavior Analysis (ABA));
• Bone growth stimulator (electrical or ultrasound);
• Chimeric antigen receptor (CAR) t-cell therapy;
• Chronic pain management program;
• Cochlear implant;
• Deep brain stimulator;
  
• Dental anesthesia and hospitalization for all Members age 9 and older;
• Electric wheelchairs;
• Gender reassignment surgery;
• Growth hormone therapy/treatment;
• Home Health Care;
• Hospice;
  
• Inpatient Admission to a Rehabilitation Facility;
• Inpatient Admissions to a Health Care Provider not participating with BCBSND;
• Insulin infusion pump, patient owned continuous glucose monitoring systems and artificial pancreas device systems;
• Limb lengthening;
• Long Term Acute Care Facility;
• Molecular and genomic testing; www.evicore.com/pages/ProviderLogin.aspx
• Negative pressure wound therapy in an outpatient setting;
• Oral appliance for obstructive sleep apnea;
• Oscillatory devices for respiratory conditions;
• Osseointegrated dental implants;
• Positron emission tomography (PET) scan;
• Programmable lymphedema pumps;
• Prosthetic Limbs controlled by microprocessors and any Prosthetic Limb replacement within 5 years;
• Proton beam therapy;
• Psychiatric and Substance Abuse Admissions to Partial Hospitalization or Residential Treatment;
• Repetitive transcranial magnetic stimulation (rTMS);
• Restricted Use Drugs; Restricted Use – Prior Approval drug list
• Sacral nerve stimulator (trial placement and permanent placement);
• Services or procedures which could be considered Cosmetic Services;
• Skilled Nursing Facility;
• Spinal cord stimulator (trial placement and permanent placement);
• Surgical treatment of obstructive sleep apnea;
• Total ankle replacement;
• Transitional Care Unit;
• Transplants except cornea and kidney;
• Vagus nerve stimulator;
• Wearable cardioverter defibrillators; and
• Wireless capsule endoscopy.

Note:

• No precertification is required when BCBSND is secondary to other insurance, unless other insurance benefits have been exhausted.
• No precertification is required for maternity admissions that result in delivery.
• This list does not apply to the Federal Employee Program (FEP).