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 11/02/2021

Topics due to be included in the Medical Policy Manual on 11/30/2021

Topics due to be included in the Medical Policy Manual on 12/31/2021

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Topics due to be included in the Medical Policy Manual on 11/02/2021:

Ado-Trastuzumab Emtansine (Kadcyla®)

Anifrolumab-fnia (Saphnelo™) (Intravenous)

Avalglucosidase alfa-ngpt (Nexviazyme™) (Intravenous)

Bevacizumab Products for the Treatment of Neoplastic Disease (Avastin®, bevacizumab-awwb [Mvasi®] and bevacizumab-bvzr [Zirabev™])

Goserelin Acetate (Zoladex®) (Subcutaneous)

Ibalizumab-uiyk (Trogarzo™)

Ipilimumab (Yervoy®)

Isatuximab-irfc (Sarclisa®)

Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids

Leuprolide Suspension (Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™) (Intramuscular/Subcutaneous)

Lurbinectedin (Zepzelca™)

Nivolumab (Opdivo®) (Intravenous)

OnabotulinumtoxinA (Botox®)

Panitumumab (Vectibix®)

Pembrolizumab (Keytruda®)

Pemetrexed (Alimta®)

Pertuzumab (Perjeta®)

Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®], Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®])

Sacituzumab Govitecan-hziy (Trodelvy®)

Trastuzumab Products - Intravenous (Herceptin®, Ontruzant®, Herzuma®, Ogivri®, Trazimera™, Kanjinti™)

Ziv-Aflibercept (Zaltrap®)

Medical Policies to be Archived on 11/02/2021:

Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis - This medical policy is no longer of value to the Commercial and BlueCare Utilization Management Departments; so, will be archived on 11/2/2021.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Peroral Endoscopic Myotomy (POEM) - This medical policy is no longer of value to the Commercial and BlueCare Utilization Management Departments; the POEMS procedure is addressed by an available MCG Guideline should it be needed. This medical policy will be archived on 11/2/2021.

Serum Tumor Markers for Gastrointestinal Cancer - This test is now considered standard medical practice and there is no longer a need to retain this medical policy.  This medical policy will be archived on 11/2/2021. 

Topics due to be included in the Medical Policy Manual on 11/30/2021:

Benralizumab (Fasenra®) (Subcutaneous)

Brexucabtagene Autoleucel (Tecartus™)

Enfortumab Vedotin-ejfv (Padcev™)

Histrelin (Supprelin® LA) (Subcutaneous Implant)

Lanreotide (Somatuline® Depot) (Subcutaneous)

Leuprolide Suspension: (Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™) (Intramuscular/Subcutaneous)

Mepolizumab (Nucala®) (Subcutaneous)

Omalizumab (Xolair®) (Subcutaneous)

Polatuzumab Vedotin-piiq (Polivy™)

Ravulizumab-cwvz (Ultomiris®)

Talimogene Laherparepvec (Imlygic™) (Intralesional)

Triptorelin (Triptodur®) (Intramuscular)

Topics due to be included in the Medical Policy Manual on 12/31/2021:

Abatacept (Orencia®) (Intravenous/Subcutaneous)

Alglucosidase Alfa (Lumizyme®) (Intravenous)

Artificial Intervertebral Disc

Canakinumab (Ilaris®) (Subcutaneous)

Casimersen (Amondys 45™)

Dexamethasone Implant (Ozurdex®) (Intravitreal)

Eteplirsen (Exondys 51™)

Fluocinolone Acetonide Implant (Iluvien®) (Intravitreal)

Fluocinolone Acetonide Implant (Retisert®) (Intravitreal)

Fluocinolone Acetonide Implant (Yutiq™) (Intravitreal)

Golimumab (Simponi ARIA®) (Intravenous)

Golodirsen (Vyondys-53™)

Infliximab Products: (Remicade®; Inflectra™; Renflexis™; Avsola™) (Intravenous)

Nusinersen (Spinraza™)

Onasemnogene Abeparvovec-xioi (Zolgensma®)

Panitumumab (Vectibix®)

Pasireotide (Signifor® LAR) (Intramuscular)

Pembrolizumab (Keytruda®)

Pemetrexed (Alimta®)

Pertuzumab (Perjeta®)

Taliglucerase alfa (Elelyso™)

Tildrakizumab-asmn (Ilumya®) (Subcutaneous)

Velaglucerase alfa (VPRIV®)

Viltolarsen (Viltepso™)

Medical Policies to be Archived on 12/31/2021:

Analysis of MGMT (O6-methylguanine-DNA methyltransferase) Promoter Methylation - This genetic test is supported by the NCCN and is considered standard/conventional practice; so, this medical policy will be archived on 12/31/2021.

Artificial Liver Assist Device for the Treatment of Liver Conditions - This is an inpatient service and there is no longer a need to retain this medical policy. This medical policy will be archived on 12/31/2021.

Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome - BCBST will transition to the available MCG Care Guideline titled Ovarian and Internal Iliac Vein Embolization (A-0567).  MCG Care Guidelines may be viewed on the Cite Guideline Transparency website: https://bcbst.access.mcg.com/index. This medical policy will be archived on 12/31/2021. 

Temporomandibular Joint (TMJ) Dysfunction: Diagnostic Studies - eviCore will utilize their policy in managing BCBSTs high-tech imaging prior authorizations for the related MRI and CT services.  This medical policy will be archived on 12/31/2021. 


Last Review Date: 10/14/2021

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