Draft Medical Policies
BlueCross BlueShield of Tennessee

BlueCross BlueShield of Tennessee works to ensure that Medical Policies are developed in an open, collaborative manner with our providers. We invite you to submit comments during the development phase of our Medical Policies.

Medical policies are developed using an evidence-based evaluation process. The medical evidence used in this process comes from several sources, including independent medical technology review organizations, the peer reviewed medical literature, and expert opinions from BCBST network specialists. We especially welcome comments that include this type of information. All Medical Policies are reviewed and approved by a panel of BCBST Medical Directors as well as board certified network physicians before final adoption by the company.


Policy Posted
Policy Removed
DMP0419-23 Levoleucovorin (Khapzory™) 04/22/19 05/22/19
DMP0419-24 Genetic Testing for Dilated Cardiomyopathy 04/22/19 05/22/19
DM0419-25 Implantable Hypoglossal Nerve Stimulation 04/22/19 05/22/19
DMP0419-27 Darbepoetin Alfa for ESRD (dialysis) 04/24/19 05/24/19
DMP0419-28 Darbepoetin Alfa for Non-ESRD (Non-Dialysis) 04/24/19 05/24/19
DMP0419-29 Epoetin Alfa-epbx for ESRD (dialysis) 04/24/19 05/24/19
DMP0419-30 Epoetin Alfa-epbx for non-ESRD (non-dialysis) 04/24/19 05/24/19
DMP0419-31 Epoetin Alfa for ESRD (Dialysis) 04/24/19 05/24/19
DMP0419-32 Epoetin Alfa for Non-ESRD (Non-Dialysis) 04/24/19 05/24/19
DMP0519-01 Irinotecan Liposome Injection 05/01/19 06/01/19
DMP0519-02 Vulvectomy 05/07/19 06/07/19
DM0519-03 Methoxy Polyethylene Glycol-Epoetin Beta-for ESRD (Dialysis 05/08/19 06/08/19
DMP0519-04 Methoxy Polyethylene Glycol-Epoetin Beta for non-ESRD (non-dialysis) 05/08/19 06/08/19
DMP0519-05 Octreotide Acetate Long-Acting Dosage Form 05/08/19 06/08/19
DMP0519-06 Chelation Therapy 05/10/19 06/10/19
DMP0519-07 Bevacizumab-awwb 05/10/19 06/10/19
DMP0519-08 Trastuzumab-dkst 05/10/19 06/10/19
DMP0519-10 Gemcitabine in Sodium Chloride Injection 05/16/19 06/16/19
DMP0519-11 Trastuzumab and Hyaluronidase-oysk 05/16/19 06/16/19
DMP0519-12 Romosozumab-aqqg 05/16/19 06/16/19
DMP0519-13 Fecal Calprotectin Testing 05/20/19 06/20/19
DMP0519-14 Mastectomy for Gynecomastia 05/20/19 06/20/19
DMP0519-15 Azacitidine 05/20/19 06/20/19
DMP0519-16 Dexamethasone Intravitreal Implant 05/20/19 06/20/19
DMP0519-17 Circulating Tumor DNA Multi-Panel Testing and Circulating Tumor Cells (Liquid Biopsy) 05/20/19 06/20/19
DMP0519-18 Fluocinolone Acetonide Intravitreal Implant for the Treatment of Uveitis 05/21/19 06/21/19
DMP0519-19 Fosnetupitant/Palonosetron 05/21/19 06/21/19
DMP0519-20 Granisetron Extended-Release Injection 05/21/19 06/21/19
DMP0519-21 Palonosetron Hydrochloride 05/21/19 06/21/19
DMP0519-22 Temozolomide for Injection 05/21/19 06/21/19
DMP0519-23 Certolizumab Pegol 05/21/19 06/21/19
DMP0519-24 Intravenous Immune Globulin (IVIG) Therapy 05/22/19 06/22/19
DMP0519-25 Ixabepilone 05/22/19 06/24/19


Medical Policy Comments:

Please reference the policy name or tracking number in your comments.
To submit comments about the draft Medical Policies:
Click the “Medical Policy Comments” above or click here: Comments or Feedback.

Comments can also be mailed to:

BlueCross BlueShield of Tennessee
Medical Policy
1 Cameron Hill Circle
Chattanooga, TN 37402