BlueCross BlueShield of Tennessee Medical Policy Manual

Hematology/Oncology

• Active Specific Immunotherapy: Melanoma Vaccine

• Adoptive Immunotherapy

• Aldesleukin (Systemic)

• Alemtuzumab

• Aminocaproic Acid

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

• Analysis of Proteomic Patterns in Serum to Identify Ovarian Cancer

• Anti-inhibitor Coagulant Complex

• Antihemophilic Factor (Factor VIII)

• Apolipoprotein B Testing for Screening, Diagnosis and Management of Dyslipidemia and Cardiovascular Disease

• Apolipoprotein E Testing for Screening, Diagnosis and Management of Dyslipidemia and Cardiovascular Disease

• Arsenic Trioxide

• Azacitidine

• Bendamustine

• Bevacizumab

• Boron Neutron Capture Therapy (BNCT) For Glioblastoma Multiforme

• Bortezomib

• Brachytherapy for Breast Cancer

• Breast Cancer Tumor Markers

• Breast Duct Endoscopy

• Breast Ductal Lavage for Cancer Risk Assessment

• Cancer Screening of the Cervix

• Capecitabine

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

• Certolizumab Pegol

• Cetuximab

• Chemoembolization for the Treatment of Surgically Unresectable Hepatocellular Carcinoma

• Computed Tomography (CT) Scanning for Lung Cancer Screening

• Cryosurgical Ablation for the Treatment of Prostate Tumors

• Cryosurgical Ablation for Treatment of Renal Tumors

• Cryosurgical Ablation of Miscellaneous Solid Tumors

• Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis of Gastrointestinal Origin

• Daily Hemodialysis in the Home

• Dasatinib

• Decitabine

• Desmopressin Acetate for Management of Hemorrhagic Episodes

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

• Digital Epiluminescence Microscopy for the Diagnosis of Skin Lesions

• Donor Leukocyte Infusion (DLI) for Hematologic Malignancies that Relapse after Allogeneic Stem Cell Transplant

• Electrical Impedance Scanning of the Breast

• Eltrombopag

• Enoxaparin Sodium

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

• Erlotinib

• Erythropoiesis-Stimulating Agents (ESAs)

• Extracorporeal Immunoadsorption (ECI) Using Protein A Columns

• Extracorporeal Photochemotherapy/Photopheresis

• Factor IX

• Factor VIIa (Recombinant)

• Fludarabine

• Fondaparinux Sodium

• Gastrointestinal Cancer Tumor Markers

• Gefitinib

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

• Genetic Testing for BRCA1 or BRCA2 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

• Granulocyte Colony Stimulating Factors (G-CSFs)

• Granulocyte-Macrophage Colony Stimulating Factors (GM-CSF)

• 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

• High-Density Lipoprotein (HDL) Subclass Testing for Screening, Diagnosis and Management of Dyslipidemia and Cardiovascular Disease

• Ibritumomab Tiuxetan

• Immunochemical Fecal Occult Blood Tests

• In Vitro Chemosensitivity and Chemoresistance Assays

• Insulin Potentiation Therapy

• Interferons Alfa (Systemic)

• Intraoperative Radiation Therapy (IORT)

• Intrauterine Laser Ablation of Placental Vessels for Twin-to-Twin Transfusion Syndrome (TTTS)

• Isolated Limb Perfusion for Malignant Melanoma

• Ixabepilone

• Lenalidomide

• Lipid Apheresis for the Treatment of Hypercholesterolemia

• Lipoprotein(a) Enzyme Immunoassay in the Management of Cardiovascular Disease

• Local or Whole Body Hyperthermia Therapy for Treatment of Cancer

• Manual Lymphedema Drainage (MLD)

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

• Nilotinib

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

• Ovarian Cancer Tumor Markers

• Paclitaxel (Protein-Bound)

• Panitumumab

• Pemetrexed

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

• Plasmapheresis / Plasma Exchange

• Plerixafor

• Positron Emission Tomography (PET) for Oncologic Applications

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

• Radiofrequency Ablation as Tumor Therapy

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

• Radiotherapy for Prostate Cancer

• Rilonacept

• Rituximab (Systemic)

• Romiplostim

• Sapropterin

• Screening Colonoscopy for Colorectal Cancer in Individuals at Average Risk

• Selective Internal Radiation Therapy (SIRT) via Microspheres for Primary and Metastatic Tumors of the Liver

• Sentinel Node Biopsy for the Staging of Breast Cancer and Malignant Melanoma

• Sorafenib

• Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions

• Sunitinib Malate

• Tandem High Dose Chemotherapy with Hematopoietic Stem Cell Support

• Temozolomide

• Temsirolimus

• Thalidomide

• Thyroidectomy for the Prevention of Medullary Thyroid Carcinoma

• Tositumomab

• Trastuzumab

• Vorinostat

• Zoledronic Acid

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