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 12/31/2019

Topics due to be included in the Medical Policy Manual on 1/30/2020

Topics due to be included in the Medical Policy Manual on 3/1/2020

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Topics due to be included in the Medical Policy Manual on 12/31/2019:

Abatacept

Canakinumab

Denosumab

Eculizumab

Gender Reassignment Surgery

Gender Reassignment Precertification Request Form

Infliximab Biosimilar Products

Inotuzumab Ozogamicin

Lanreotide

Pegfilgrastim Biosimilar Products

Pegfilgrastim

Pembrolizumab

Testosterone Pellets for Subcutaneous Implantation

Tildrakizumab-asmn

Tocilizumab

Zoledronic Acid

Topics due to be included in the Medical Policy Manual on 1/30/2020:

AbobotulinumtoxinA

Absorbable Nasal Implant for the Treatment of Nasal Valve Collapse

Aflibercept

Atezolizumab

Avelumab

Belinostat

Bendamustine HCl (Bendeka®)

Bendamustine HCl (Treanda®)

Bevacizumab Biosimilar Products for the Treatment of Neoplastic Disease

Bevacizumab for the Treatment of Neoplastic Disease

Blinatumomab

Bortezomib

Bortezomib (Velcade)

Complementary and Alternative Medicine

Digital Breast Tomosynthesis (3D Mammogram)

Eculizumab

Granisetron Extended-Release Injection

Imiglucerase

IncobotulinumtoxinA

Ipilimumab

Lanadelumab-flyo

Levoleucovorin

Natalizumab

Nivolumab (Intravenous)

Obinutuzumab

Ocrelizumab

OnabotulinumtoxinA

Paclitaxel (Protein-Bound)

Palonosetron Hydrochloride

Pasireotide

RimabotulinumtoxinB

Rituximab

Rituximab Biosimilar Products

Medical Policies to be Archived on 1/30/2020:

Ablation Treatments for Barrett’s Esophagus - BCBST will be archiving this medical policy and transitioning over to using the available MCG Care Guideline Esophagogastroduodenoscopy (EGD), UGI Endoscopy (A-0203) that addresses this same procedure. MCG’s clinical indication criteria are based on the latest National Comprehensive Cancer Network (NCCN) guideline recommendations.

BRCA1, BRCA2 and PALB2 Testing for Breast, Ovarian and Other Cancers - BCBST will be archiving this medical policy and transitioning over to using two Utilization Management Guidelines (i.e., modified MCG guidelines) that address these same tests. The MCG clinical indication criteria requirements are very similar to the current BCBST medical policy criteria. Those Utilization Management Guidelines can be viewed on BCBST’s Upcoming Utilization Management Guidelines site. To view those documents select the “Upcoming Utilization Management Guidelines” link on this web page: https://www.bcbst.com/providers/coverage-policies-guidelines/index.page.

Genetic Testing (CFTR-mutations) for Cystic Fibrosis - BCBST will be archiving this medical policy and transitioning over to using a Utilization Management Guideline (i.e., modified MCG guideline) Cystic Fibrosis - CFTR Gene and Mutation Panel (A-0597) that addresses this test. Utilization Management Guidelines can be viewed on BCBST’s Upcoming Utilization Management Guidelines site. To view those documents select the “Upcoming Utilization Management Guidelines” link on this web page: https://www.bcbst.com/providers/coverage-policies-guidelines/index.page.

Genetic Testing, Including Chromosomal Microarray Analysis and Next-Generation Sequencing Panels, for Prenatal Evaluation and Evaluation of Children with Developmental Delays/Intellectual Disability, Autism Spectrum Disorder and/or Congenital Anomalies - BCBST will be archiving this medical policy and transitioning over to using the seven available MCG Care Guidelines that address these tests. The BCBST medical policy content was based on the same sources as those used by MCG; thus, the criteria requirements are very similar. The most significant difference is that MCG does not have an age related limitation.

Home Phototherapy for Neonatal Jaundice - BCBST will be archiving this medical policy and transitioning over to using a Utilization Management Guideline (i.e., modified MCG guideline) Home Phototherapy Device for Neonatal Hyperbilirubinemia (A-0883) on an as needed basis. Utilization Management Guidelines can be viewed on BCBST’s Upcoming Utilization Management Guidelines site. To view those documents select the “Upcoming Utilization Management Guidelines” link on this web page: https://www.bcbst.com/providers/coverage-policies-guidelines/index.page.

Tumor-Treatment Fields Therapy for Glioblastoma - BCBST will be archiving this medical policy and transitioning over to using the available MCG Care Guideline Alternating Electric Field Therapy (A-0930) that addresses this same procedure. The MCG clinical indication criteria and BCBST medical policy criteria are very similar; MCG’s age limit requirement is based on the latest FDA labeling information.

Topics due to be included in the Medical Policy Manual on 3/1/2020:

Axicabtagene Ciloleucel

Benralizumab

C1 Esterase Inhibitor (Human) (Berinert®)

C1 Esterase Inhibitor (Human) (Cinryze®)

C1 Esterase Inhibitor (recombinant) (Ruconest®)

C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda®)

Collagenase Clostridium Histolyticum

Copanlisib

Daratumumab

Ecallantide

Gemtuzumab Ozogamicin

Hyaluronan Derivatives for Intra-Articular Injection

Icatibant

Intravenous Immune Globulin (IVIG) Therapy

Mepolizumab

Moxetumomab pasudotox-tdfk

Omalizumab

Patisiran

Pegaptanib Sodium

Pegfilgrastim Biosimilar Products

Ranibizumab

Reslizumab

Tisagenlecleucel

 


Last Review Date: 12/13/2019

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