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 8/30/2019

Topics due to be included in the Medical Policy Manual on 9/30/2019

Topics due to be included in the Medical Policy Manual on 10/1/2019

Topics due to be included in the Medical Policy Manual on 10/31/2019

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Topics due to be included in the Medical Policy Manual on 8/30/2019:

Accelerated Partial Breast Irradiation

Ado-Trastuzumab Emtansine

Bevacizumab-awwb

Darbepoetin Alfa for ESRD (dialysis)

Darbepoetin Alfa for Non-ESRD (Non-Dialysis)

Epoetin Alfa for ESRD (Dialysis)

Epoetin Alfa for Non-ESRD (Non-Dialysis)

Epoetin Alfa-epbx for ESRD (dialysis)

Epoetin Alfa-epbx for non-ESRD (non-dialysis)

Genetic Testing for Dilated Cardiomyopathy

Implantable Hypoglossal Nerve Stimulation

Infliximab

Infliximab-abda

Infliximab-dyyb

Intraoperative Radiation Therapy (IORT)

Irinotecan Liposome Injection

Levoleucovorin (Fusilev®)

Levoleucovorin (Khapzory™)

Methoxy Polyethylene Glycol-Epoetin Beta - ESRD (Dialysis)

Methoxy Polyethylene Glycol-Epoetin Beta - non-ESRD (non-dialysis)

Octreotide Acetate Long-Acting Dosage Form

Trastuzumab-dkst

Topics due to be included in the Medical Policy Manual on 9/30/2019:

Alpha1-Proteinase Inhibitor Therapy

Avelumab

Azacitidine

Burosumab-twza

Certolizumab Pegol

Chelation Therapy

Circulating Tumor DNA Multi-Panel Testing and Circulating Tumor Cells (Liquid Biopsy)

Dexamethasone Intravitreal Implant

Fecal Calprotectin Testing

Fluocinolone Acetonide Intravitreal Implant for the Treatment of Uveitis

Fosnetupitant /Palonosetron

Gemcitabine in Sodium Chloride Injection

Granisetron Extended-Release Injection

Intravenous Immune Globulin (IVIG) Therapy

Ixabepilone

Ocriplasmin

Palonosetron Hydrochloride

Pembrolizumab

Pemetrexed

Romosozumab-aqqg

Subcutaneous Immune Globulins

Temozolomide for Injection

Trastuzumab and Hyaluronidase-oysk

Topics due to be included in the Medical Policy Manual on 10/1/2019:

Mastectomy for Gynecomastia

Vulvectomy

Topics due to be included in the Medical Policy Manual on 10/31/2019:

Belimumab

Bevacizumab-bvzr

Brentuximab Vedotin

Cetuximab

Dynamic Spinal Visualization and Vertebral Motion Analysis

Eribulin Mesylate

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

Hyaluronan Derivatives for Intra-Articular Injection

Ipilimumab

Nivolumab

Nusinersen

Obinutuzumab

Onasemnogene

Pegfilgrastim

Pegfilgrastim-cbqv

Pegfilgrastim-jmdb

Pembrolizumab

Pemetrexed

Pertuzumab

Polatuzumab-Vedotin-piiq

Proton Beam Therapy - Tentative effective date of 10/31/2019

Transcranial Magnetic Stimulation (TMS)

Trastuzumab

Trastuzumab-anns

Trastuzumab-dkst

Trastuzumab-dttb

Trastuzumab-pkrb

Whole Exome and Genome Sequencing

 


Last Review Date: 8/15/2019

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