Upcoming Medical Policies
BlueCross BlueShield of Tennessee

Each medical policy listed below will become effective on the date indicated, and will be included in the Medical Policy Manual for BlueCross BlueShield of Tennessee on that effective date.

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 opinions from appropriate network specialists. All Medical Policies are reviewed by a panel of internal and external physicians before being adopted by the company.

Topics due to be included in the Medical Policy Manual on 5/31/2019

Topics due to be included in the Medical Policy Manual on 6/30/2019

Topics due to be included in the Medical Policy Manual on 7/2/2019

Topics due to be included in the Medical Policy Manual on 7/31/2019

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Topics due to be included in the Medical Policy Manual on 5/31/2019:

Ado-Trastuzumab Emtansine

Aldesleukin

Alemtuzumab

Asparaginase Erwinia chrysanthemi

Atezolizumab

Belinostat

Bevacizumab for the Treatment of Neoplastic Disease

Calaspargase Pegol-mknl

Cetuximab

Elotuzumab

Extracorporeal Shock Wave Therapy for Wounds

Fecal Analysis in the Diagnosis of Intestinal Disorders

Home Pulse Oximetry

Inotersen

Ipilimumab

Magnetic Resonance Imaging (MRI) of the Breast

Omacetaxine

Panitumumab

Patisiran

Pegaspargase

Pembrolizumab

Pemetrexed

Pneumatic Compression Pumps

Pralatrexate

Ramucirumab

Ravulizumab-cwvz

Rituximab

Rituximab-abbs

Romiplostim

Tagraxofusp-erzs

Trastuzumab

Trastuzumab-dttb

Ziv-Aflibercept

Topics due to be included in the Medical Policy Manual on 6/30/2019:

Human Amniotic Membrane Grafts and Amniotic Fluid Injections

Prostatic Urethral Lift

Axicabtagene

Bendamustine HCl (Bendeka®)

Bendamustine HCl (Treanda®)

Bortezomib

Bortezomib (Velcade®)

Brentuximab Vedotin

Burosumab-twza

Eculizumab

Elosulfase Alfa

Nivolumab

Obinutuzumab

Paclitaxel (Protein-Bound)

Pertuzumab

Romidepsin

Vestronidase alfa-vjbk

Topics due to be included in the Medical Policy Manual on 7/2/2019:

Gender Reassignment Surgery

Topics due to be included in the Medical Policy Manual on 7/31/2019:

AbobotulinumtoxinA

Aflibercept

Atezolizumab

Belinostat

Bevacizumab for the Treatment of Neoplastic Disease

Cetuximab

Epoprostenol

Goserelin Acetate Implant

Ibalizumab-uiyk

IncobotulinumtoxinA

Mepolizumab

Ofatumumab

Olaratumab

OnabotulinumtoxinA

Palivizumab

Panitumumab

Pembrolizumab

Ramucirumab

RimabotulinumtoxinB

Rituximab

Rituximab and Hyaluronidase Human Injection

Trabectedin

Trastuzumab

Trastuzumab and Hyaluronidase-oysk

Trastuzumab-dttb

Trastuzumab-pkrb

Trastuzumab-qyyp

Medical Policies to be Archived:

Computer-Aided Detection of Malignancy with Magnetic Resonance Imaging of the Breast - Given the changes to the available procedure codes, it’s no longer practical to maintain this medical policy. 

Hematopoietic Cell Transplantation for Autoimmune Diseases - This medical policy will be archived, since there is now a matching MCG General Recovery Guideline (GRG) position for use.

Human Epidermal Receptor Type 2 Testing - This medical policy will be archived, since there is now a matching MCG guideline for use.  Once the medical policy is archived the MCG guideline titled Breast Cancer - HER2 Testing (ACG: A-0766) will be used by BCBST.  That MCG guideline will be available on 7/31/2019 within Cite Guideline Transparency on the bcbst.com Provider page for Utilization Management Resources: https://www.bcbst.com/providers/utilization-management-resources.page

Positron Emission Tomography (PET) for Oncologic Applications - For participants in BCBST’s High-Tech Imaging Program, eviCore’s guideline is used in adjudicating prior authorizations; prior authorizations for this service are not required for BCBST members who are not participating in our High-Tech Imaging Program.  This BCBST medical policy has matched the eviCore guideline for a number of years, but it is no longer necessary to retain this redundant position document.  Should a reference position document be needed for a member who is not in the High-Tech Imaging Program an MCG Guideline  (i.e., Tumor Imaging Positron Emission Tomography and PET-CT [ACG: A-0098]) will be utilized. That MCG guideline will be available on 7/31/2019 within Cite Guideline Transparency on the bcbst.com Provider page for Utilization Management Resources: https://www.bcbst.com/providers/utilization-management-resources.page

Radiofrequency Ablation of Tumors - This medical policy will be archived since it no longer reflects the latest National Comprehensive Cancer Network (NCCN) recommendations.  Once the medical policy is archived, the MCG guideline titled Radiofrequency Ablation of Tumor (ACG: A-0718) will be used by BCBST; this guideline mirrors the latest NCCN recommendations. That MCG guideline will be available on 7/31/2019 within Cite Guideline Transparency on the bcbst.com Provider page for Utilization Management Resources: https://www.bcbst.com/providers/utilization-management-resources.page


Last Review Date: 5/15/2019

Medical Policy Comments:

Please reference the policy name in your comments.
To submit comments about the upcoming 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