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 4/30/2020

Topics due to be included in the Medical Policy Manual on 6/2/2020

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Topics due to be included in the Medical Policy Manual on 4/30/2020

Bortezomib (Velcade)

Breast Cancer Gene Expression Assays

Brentuximab Vedotin

Carfilzomib

Cemiplimab-rwlc

Durvalumab

Fosnetupitant Palonsetron

Ipilimumab

Measurement of Serum Antibodies to Selected Biologic Agents

Panitumumab

Ravulizumab-cwvz

Rituximab and Hyaluronidase Human Injection

Romiplostim

Serum Antibodies for the Diagnosis and Management of Inflammatory Bowel Disease

Trastuzumab and Hyaluronidase-oysk

Medical Policies to be Archived on 4/30/2020:

Computed Tomography Perfusion Imaging - This medical technology is now considered standard / conventional practice; thus, BCBST will be archiving this medical policy effective April 30, 2020.

Cooling Devices Used in the Outpatient Setting - There is no longer a need for BCBST to maintain and utilize this medical policy on a regular basis; thus, BCBST will be archiving this policy effective April 30, 2020.

Mechanical Stretch Devices for the Treatment of Joint Stiffness - BCBST will be archiving this medical policy effective April 30, 2020 and transition over to utilizing the two available MCG Guidelines in the adjudication of claims and request. These two MCG Guideline can be viewed on 3/1/2020 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index

Olaratumab - this medical policy will be archived on 4/30/2020; this product is no longer marketed in the United States.

Topics due to be included in the Medical Policy Manual on 6/2/2020:

Abatacept

Aldesleukin

Avelumab

Belinostat

Certolizumab Pegol

Cetuximab

Epoprostenol for Continuous Intravenous Infusion

Eribulin Mesylate

Nelarabine

Omacetaxine Mepesuccinate

Pemetrexed

Pertuzumab

Pralatrexate

Ramucirumab

Tocilizumab (Intravenous)

Treprostinil for Continuous Subcutaneous/Intravenous Infusion

Voretigene Neparvovec-rzyl


Last Review Date: 4/1/2020

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