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 1/31/2019

Topics due to be included in the Medical Policy Manual on 3/2/2019

Topics due to be included in the Medical Policy Manual on 4/2/2019

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Topics due to be included in the Medical Policy Manual on 1/31/2019:

Autonomic Nervous System Testing

Bortezomib

Bortezomib (Velcade®)

BRCA1, BRCA2 and PALB2 Testing for Breast, Ovarian and Other Cancers

Canakinumab

Genetic Testing (CFTR mutations) for Cystic Fibrosis

Human Papillomavirus (HPV) Vaccine

Hyaluronan Derivatives for Intra-Articular Injection

Intravenous Immune Globulin (IVIG) Therapy

Lanadelumab-flyo

Lanreotide

Mogamulizumab-kpkc

Moxetumomab pasudotox-tdfk

Neuromuscular Electrical Stimulation

Paclitaxel (Protein-Bound)

Panitumumab

Pasireotide

Patisiran

Pembrolizumab

Testosterone Pellets for Subcutaneous Implantation

Tocilizumab (Intravenous)

Trastuzumab

Triptorelin Extended-Release Injectable Suspension

Urinary Biomarkers for Screening Bladder Cancer and Pre-cancerous Colon Polyps

Topics due to be included in the Medical Policy Manual on 3/2/2019:

Agalsidase Beta

Alemtuzumab

Atezolizumab

Avelumab

Balloon Dilation of the Eustachian Tube

Belinostat

Bendamustine HCl (BendekaŽ)

Bendamustine HCl (TreandaŽ)

Cemiplimab-rwlc

Certolizumab Pegol

Complementary and Alternative Medicine

Durvalumab

Ecallantide

Eculizumab

Elapegademase-lvlr

Eribulin Mesylate

Fluocinolone Acetonide Intravitreal Implant

Idursulfase

Inotersen

Ipilimumab

Laronidase

Natalizumab

Nivolumab (Intravenous)

Lymphatic Physiologic Microsurgery for Breast Cancer-Related Lymphedema

Omalizumab

Palonosetron Hydrochloride

Panitumumab

Pegademase Bovine

Pegaptanib Sodium

Pegfilgrastim

Pemetrexed

Positron Emission Tomography (PET) for Oncologic Applications

Ranibizumab

Reslizumab

Romiplostim

Serum Tumor Markers for Gastrointestinal Cancer

Subtalar Arthroereisis

Tumor-Treatment Fields Therapy for Glioblastoma

Medical Policies to be Archived:

EGFR Mutation Analysis for Individuals with NSCLC - This medical policy document will be archived (i.e., no longer used) by BCBST as of March 2, 2019.

Occupational Therapy and Physical Therapy for Autism Spectrum Disorder - This medical policy document will be archived (i.e., no longer used) by BCBST as of April 2, 2019.

Virtual Colonoscopy (Computed Tomography Colonography) - This medical policy document will be archived (i.e., no longer used) by BCBST as of March 2, 2019.

Topics due to be included in the Medical Policy Manual on 4/2/2019:

Abatacept

AbobotulinumtoxinA

Aflibercept

C1 Esterase Inhibitor (Cinryze®)

C1 Esterase Inhibitor (Ruconest®)

C1 Esterase Inhibitor (Berinert®)

C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda)

Collagenase Clostridium Histolyticum

Copanlisib

Galsulfase

Gemtuzumab Ozogamicin

Gender Reassignment Surgery

Granisetron Extended-Release Injection

Icatibant

IncobotulinumtoxinA

Infliximab-abda

Infliximab-dyyb

Levoleucovorin (Khapzory)

Ocrelizumab

Olaratumab

OnabotulinumtoxinA

Pegfilgrastim-cbqv

RimabotulinumtoxinB

Tildrakizumab

Tisagenlecleucel

Tocilizumab

Medical Policies to be Archived:

Capecitabine - This medical policy document will be archived (i.e., no longer used) by BCBST as of April 2, 2019.


Last Review Date: 1/17/2019

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