BlueCross BlueShield of Tennessee Medical Policy Manual

Hematology/Oncology

• Active Specific Immunotherapy: Melanoma Vaccine

• Adoptive Immunotherapy

• Alemtuzumab

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

• Analysis of Proteomic Patterns in Serum to Identify Ovarian Cancer

• Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas

• Azacitidine

• Bendamustine

• Bevacizumab for the Treatment of Neoplastic Disease

• Boron Neutron Capture Therapy (BNCT) For Glioblastoma Multiforme

• Bortezomib

• Brachytherapy for Breast Cancer

• Breast Duct Endoscopy

• Breast Ductal Lavage for Cancer Risk Assessment

• Brentuximab Vedotin

• Cabazitaxel

• Carbogen (95% Oxygen, 5% Carbon Dioxide) Inhalation in Cancer Treatment

• Certolizumab Pegol

• Cervical Cancer Screening Technologies (Pap/HPV/Speculoscopy/Cervicography)

• Cetuximab

• Computed Tomography (CT) Scanning for Lung Cancer Screening

• Crisantaspase

• Cryosurgical Ablation for the Treatment of Prostate Tumors

• Cryosurgical Ablation for Treatment of Renal Tumors

• Cryosurgical Ablation of Miscellaneous Solid Tumors

• Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy

• Daily Hemodialysis in the Home

• Degarelix Acetate

• Detection and Quantification of Circulating Tumor Cells in the Management of Individuals with Cancer

• Digital Epiluminescence Microscopy for the Diagnosis of Skin Lesions

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

• Electrical Impedance Scanning of the Breast

• Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Individuals with Non-Small Cell Lung Cancer (NSCLC)

• Eribulin Mesylate

• Erythropoiesis-Stimulating Agents (ESAs)

• Extracorporeal Immunoadsorption (ECI) Using Protein A Columns

• Extracorporeal Photochemotherapy/Photopheresis

• Factor IX

• Factor VIIa (Recombinant)

• Filgrastim and Pegfilgrastim

• Gene-based Tests for Screening, Detection, and/or Management of Prostate Cancer

• Genetic Testing for BRCA1, BRCA2 or CHEK2 for Breast or Ovarian Cancer

• Genetic Testing for Cutaneous Malignant Melanoma

• Genetic Testing for Inherited Susceptibility to Colorectal Cancer

• Genetic Testing for Medullary Thyroid Carcinoma

• Genotyping for Chronic Hepatitis C

• Hematopoietic Stem Cell Transplant for Breast Cancer

• Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults

• Hematopoietic Stem Cell Transplantation in the Treatment of Germ Cell Tumors

• High Dose Chemotherapy with Autologous Stem-Cell Transplant for Primary Amyloid Light-Chain (AL) Amyloidosis

• High Dose (Myeloablative) Chemotherapy with Bone Marrow, Peripheral Stem Cell, or Cord Blood Transplant for Hematopoietic Stem Cell Support

• Immunochemical Fecal Occult Blood Tests

• In Vitro Chemosensitivity and Chemoresistance Assays

• Intraoperative Radiation Therapy (IORT)

• Ipilimumab

• Isolated Limb Perfusion/Infusion for Malignant Melanoma

• Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease

• Local or Whole Body Hyperthermia Therapy for Treatment of Cancer

• Low-Density Lipid Apheresis

• Manual Lymphedema Drainage (MLD)

• Microarray-based Gene Expression Testing for Cancers of Unknown Primary

• Molecular Anatomic Pathology Testing

• Non-BRCA Breast Cancer Risk Assessment

• Nonmyeloablative Allogeneic Stem Cell Transplantation (Reduced Intensity Stem Cell Transplant) for Treatment of Malignancy

• Ofatumumab

• Ovarian Cancer Tumor Markers

• Panitumumab

• Pemetrexed

• Photodynamic Therapy (PDT) for the Treatment of Cancer, including Barrett's Esophagus

• Plasma Exchange

• Positron Emission Mammography

• Positron Emission Tomography (PET) for Oncologic Applications

• Pralatrexate

• Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses

• Proton or Helium Ion Beam (Charged Particle) Radiation Therapy

• Radioembolization for Primary Tumors of the Liver and Metastatic Tumors to the Liver

• Radiofrequency Ablation for Treatment of Tumors

• Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) with Indium-111 Capromab Pendetide for Prostate Cancer

• Radiotherapy for Prostate Cancer

• Rilonacept

• Rituximab (Systemic)

• Romidepsin

• Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

• Screening Colonoscopy for Colorectal Cancer in Individuals at Average Risk

• Serum Biomarker Human Epididymis Protein 4 (HE4)

• Serum Tumor Markers for Breast Malignancies

• Serum Tumor Markers for Gastrointestinal Cancer

• Sipuleucel-T

• Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions

• Tandem High Dose Chemotherapy with Hematopoietic Stem Cell Support

• Temozolomide

• Thyroidectomy for the Prevention of Medullary Thyroid Carcinoma

• Tositumomab

• Transcatheter Hepatic Arterial Chemoembolization

• Treatments of Twin-to-Twin Transfusion Syndrome (TTTS)

• Zoledronic Acid

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