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 07/31/2024

Topics due to be included in the Medical Policy Manual on 08/30/2024

Medical Policies to be Archived on 09/01/2024

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Topics due to be included in the Medical Policy Manual on 7/31/2024:

Step Therapy Requirements for Provider Administered Specialty Medications

Aldesleukin (Proleukin®)

Artificial Intervertebral Disc

Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®

Bortezomib (Velcade®; Bortezomib)

Carfilzomib (Kyprolis®)

Cemiplimab-rwlc (Libtayo®)

Ciltacabtagene Autoleucel (Carvykti™)

Daratumumab (Darzalex®)

Daratumumab and hyaluronidase-fihj (Darzalex Faspro®)

Denosumab (Xgeva®)

Evinacumab-dgnb (Evkeeza™)

Golimumab (Simponi ARIA®)

Idecabtagene Vicleucel (Abecma®)

Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™), Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra), inflixima

Lumasiran (Oxlumo®)

Nvolumab (Opdivo®

Nusinersen (Spinraza™)

Sirolimus protein-bound particles for injectable suspension (albumin-bound) (Fyarro™)

Spesolimab (Spevigo®)

Teclistamab-cqyv (Tecvayli™)

Zoledronic Acid (Reclast®)

Zoledronic Acid (Zometa®), Zoledronic Acid

Medical Policies to be Archived on 7/31/2024:

Prostatic Urethral Lift - BCBST plans to archive this medical policy document on 7/31/2024 and transition over to using an available MCG guideline: Urologic Surgery or Procedure GRG that contains similar clinical indication criteria.

Retinal Prosthesis - BCBST plans to archive this medical policy document on 7/31/2024. Devices of this type are no longer available on the market; the last device was discontinued in 2019.

Topics due to be included in the Medical Policy Manual on 8/30/2024:

Axicabtagene Ciloleucel (Yescarta®)

Bendamustine Products (Treanda®, Belrapzo®, Bendeka®, Vivimusta™, Bendamustine)

Bio-Engineered Skin and Soft Tissue Substitutes

Ciltacabtagene Autoleucel (Carvykti™)

Faricimab-svoa (Vabysmo™)

Human Amniotic Membrane Grafts and Amniotic Fluid Injections

Idecabtagene Vicleucel (Abecma®

Ipilimumab (Yervoy®)

Irinotecan Liposome Injection (Onivyde®)

Isatuximab-irfc (Sarclisa®)

Lanreotide (Somatuline® Depot; Lanreotide)

Lisocabtagene Maraleucel (Breyanzi®)

Octreotide Suspension (Sandostatin® LAR)

Remdesivir (Veklury®) as an Outpatient Treatment of COVID-19 (Intravenous)

Spesolimab (Spevigo®)

Pharmacy Policies to be Archived on 8/30/2024:

Ranibizumab Susvimo - BCBST plans to archive this medical policy document on 8/30/2024 as it is no longer in use.

Medical Policies to be Archived on 9/01/2024:

Circulating Tumor DNA Multi-Panel Testing and Circulating Tumor Cells (Liquid Biopsy) - BCBST will transition over to using the MCG Care Guideline titled Oncology Companion Diagnostic Testing - Guardant360 CDx (ACG: A-1056) on 9/1/2024. The MCG Care Guidelines may be viewed on 9/1/2024 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Genetic Testing for Dilated Cardiomyopathy - BCBST will transition over to using the MCG Care Guideline titled Familial Dilated Cardiomyopathy - Gene and Gene Panel Testing (ACG: A-0648) on 9/1/2024. The MCG Care Guidelines may be viewed on 9/1/2024 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies - BCBST will transition over to using the MCG Care Guideline titled Charcot-Marie-Tooth Hereditary Neuropathy - Gene and Gene Panel Testing (ACG: A-0691) on 9/1/2024.The MCG Care Guidelines may be viewed on 9/1/2024 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Genetic Testing for Thoracic Aortic Aneurysms and Dissections - BCBST will transition over to using the MCG Care Guideline titled Familial Thoracic Aortic Aneurysm and Aortic Dissection - Gene Testing and Gene Panels (ACG: A-0778) on 9/1/2024.The MCG Care Guidelines may be viewed on 9/1/2024 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Functional Magnetic Resonance Imaging - BCBST will transition over to using the MCG Care Guideline titled Brain Functional MRI (ACG: A-0539) on 9/1/2024.The MCG Care Guidelines may be viewed by using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Noninvasive Fractional Flow Reserve Measurement - BCBST will be archiving this medical policy document on 09/01/2024.

Positron Emission Mammography - BCBST will transition over to using the MCG Care Guideline titled Tumor Imaging Positron Emission Tomography (PET) and PET-CT (ACG: A-0098) on 9/1/2024.The MCG Care Guidelines may be viewed by using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Positron Emission Tomography (PET) for Miscellaneous Applications - BCBST will transition over to using the MCG Care Guideline titled Brain Positron Emission Tomography (PET) (ACG: A-0096) on 9/1/2024.The MCG Care Guidelines may be viewed on 9/1/2024 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Last Review Date: 7/1/2024