BlueCross BlueShield of Tennessee Medical Policy Manual

Women's Health

• Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

• Analysis of Proteomic Patterns in Serum for Early Detection of Cancer

• Brachytherapy and Accelerated Partial Breast Irradiation for Breast Cancer

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

• Breast Augmentation / Mammaplasty (Non-Cancerous)

• Breast Cancer Gene Expression Assays

• Breast Implant Removal

• Breast Reconstructive and Symmetry Surgery Following Mastectomy

• Computer-Aided Detection of Malignancy with Magnetic Resonance Imaging of the Breast

• Cryosurgical Ablation of Miscellaneous Solid Tumors

• Cytologic Evaluation in Breast Cancer Risk Assessment

• Digital Breast Tomosynthesis

• Electrical Impedance Scanning of the Breast

• Endometrial Ablation

• Fractional Laser Treatment of Vulvovaginal Atrophy

• Genetic Testing for CHEK2 Mutations for Breast Cancer

• Human Epidermal Receptor Type 2 (HER 2) Testing

• Human Papillomavirus (HPV) Vaccine

• Intensity-Modulated Radiotherapy (IMRT) of the Breast and Lung

• Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids

• Magnetic Resonance Imaging (MRI) of the Breast

• Mammography Screening

• MRI-Guided Focused Ultrasound (MRgFUS)

• Multitarget Polymerase Chain Reaction (PCR) Testing for the Diagnosis of Bacterial Vaginosis

• Nonfamilial Genetic Testing for Breast Cancer Risk Assessment

• Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

• Ovarian Cancer Tumor Markers

• Reduction Mammaplasty (Non-Cancerous)

• Salivary Testing for Steroid Hormone Levels

• Serum Biomarker Human Epididymis Protein 4 (HE4)

• Serum Tumor Markers for Breast Malignancies

• Vulvectomy

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