Hematology and Oncology
MEDICAL POLICY GROUP Co-chairs Ben Kruskal, MD, PhD, FAAP, FIDSA Medical Director for Clinical Operations Stephania Klimov, Clinical Pharmacist, Pharmacy Operations

February 24th 2026 9-11 AM Conference call only.
Please email ebr@bcbsma.com for more information.

Invited: Benjamin Kruskal, MD, PhD, FAAP, FIDSA, co-chair (Medical Director, Clinical Operations); Ashley Yeats, MD (Vice President, Medical Operations); Satya Dondapati, MD (Senior Medical Director, Medical Operations); Theresa Rines, CPC (Director, Medical Policy Administration); Adam Licurse, MD (Senior Medical Director, Medical Operations); Grace Baker, MSW, LCSW (Medical Policy Administration); Shelby Patterson, RN, BSN, (Medical Policy Administration); Ka Lee Yang, RN, BSN (Medical Policy Administration);

Invited Physician Guest(s): Representatives from the Massachusetts Society of Hematology and Oncology

Policies with Upcoming Coverage Updates • Carelon Updates • Radiation Oncologic Guidelines, April 4th, 2026 • Carelon Guidelines MP 929: Policy revised. HCPCS code A9616 added. Prior authorization is required through Carelon. • Genetic testing Guidelines, April 4th, 2026 New Policies Tumor Treating Fields Therapy MP (111) December 1, 2025

New medical policy describing medically necessary indications for newly diagnosed glioblastoma and investigational indications including but not limited to malignant pleural mesothelioma and non-small cell lung cancer.
Retired Policies

Policies with Coverage Updates in the Past 12 Months Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms (155)

10/2025 Clarified coding information. 12/2025. Hematopoietic Cell Transplantation for Hodgkin Lymphoma (207) 10/2025 Coding information clarified. 12/2025. Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors (247) 10/2025 Clarified coding information. 12/2025. Serum Tumor Markers for Breast and 10/2025 Clarified coding information. 12/2025.

Gastrointestinal Malignancies (538) Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening (557)

6/2025 Policy clarified to specify Colosense to the policy statement. 12/2025. Biompedance Devices for Detection of Lymphedema (261) 12/2025 Annual policy review. Policy updated with literature review through June 16, 2025; no references added. Policy statements revised to medically necessary with criteria based on clinical input. 12/2025. Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer (204) 10/2025 Clarified coding information. 12/2025. Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults (191) 10/2025 Coding information clarified. 12/2025. Hematopoietic Cell Transplantation for Non- Hodgkin Lymphomas (143) 10/2025 Clarified coding information. 12/2025. Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (354) 12/2025 Annual policy review. Policy statements for use of pneumatic compression pumps for lymphedema were revised to medically necessary chest and trunk use with criteria. Evidence review and medically necessary policy statement added for non-pneumatic compression pumps with criteria. Use of compression pumps for head and neck lymphedema was maintained as investigational in light of ongoing evidence generation. Coding information clarified. Effective 12/1/2025. 12/2025. Engineered T-Cell Therapy for Multiple Myeloma (942) 6/2025 Updated policy name to streamline all CAR-T MP titles. Updated Idecabtagene criteria, removed belantamab due to removal of FDA indication.
12/2025. Factor and Non-Factor Anti-Hemophilic Drugs (360)

11/2025 Updated FDA labeling for Alhemo and updated formatting and references. 12/2025. Adjunct Medications to Support Hematopoietic Stem Cell Transplantation and its Complications (028) Policy revised. Ryzneuta added to the policy. Policy title updated (formerly known as Omidubicel as Adjunct Treatment for Hematologic Malignancies). September 15, 2025. Oncology Drugs (409) Policy revised. Revuforj added to the policy. September 15, 2025. Engineered TCell Therapy for Leukemia and Lymphoma (formerly Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma) (066) Policy revised.
Updated policy name to streamline CAR-T medical policy titles. Added new drug Aucatzyl. August, 1st, 2025. Engineered TCell Therapy for Synovial Sarcoma (Tecelra®) (213) New pharmacy policy describing medically necessary and investigational indications. Prior authorization request form for Engineered T-Cell Therapy for Synovial Sarcoma (Tecelra®) #222. June 1, 2025.

Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung (188) New medical policy describing investigational indications. Irreversible electroporation is investigational for treatment of liver, pancreatic, kidney and lung cancer. April 1, 2025.

Policies with No Coverage Updates in past 12 months:

1. Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies (634)
2. Breast Duct Endoscopy (493)
3. CA 125 (503)
4. Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone (260)
5. Cryosurgical Ablation of Primary or Metastatic Liver Tumors (633)
6. Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm (009)
7. Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer (715)
8. Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management - Ductal Lavage and Suction Collection Systems (492)
9. Extracorporeal Photopheresis (248)
10. Fentanyl, oral-transmucosal (113)
11. Focal Treatments for Prostate Cancer (733)
12. Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery (546)
13. Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies (048)
14. In Vivo Analysis of Colorectal Polyps (521)
15. Insulin Potentiation Therapy (532)
16. Interferons Alpha and Gamma (052)
17. Melanoma Vaccines (453)
18. Microwave Tumor Ablation (912)
19. Multimarker Serum Testing Related to Ovarian Cancer (249)
20. Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus (454)
21. Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Products Used with Autologous Bone Marrow) (254)
22. Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer (709)
23. Radioembolization for Primary and Metastatic Tumors of the Liver (292)
24. Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors (259)
25. Radiofrequency Ablation of Primary or Metastatic Liver Tumors (286)
26. Saturation Biopsy for Diagnosis and Staging of Prostate Cancer (307)
27. Scintimammography/Breast-Specific Gamma Imaging/Molecular Breast Imaging (494)
28. Serum Biomarker Human Epididymis Protein 4 (HE4) (290)
29. Systems Pathology in Prostate Cancer (250)
30. Tumor Markers for Diagnosis and Management of Cancer (167)

31. Whole Body Computed Tomography Scan as a Screening Test (447)

    Reference Policies Outpatient Prior Authorization Code List (072) New policy outlining procedure codes that require prior authorization when performed in the outpatient setting.

    Medicare Advantage Management (132) Medicare Advantage Management guide. We have begun removing all of the Medicare Advantage information from our medical policies. We have listed out any National Coverage Determination or Local Coverage Determination with the corresponding Medical Policy
    Medicare Advantage Part B Step Therapy (020)

    New medical policy outlining associated non-oncology indications for drugs with both oncology and non-oncology indications. For the management of oncology or supportive care indications, please see

related policies above that are managed by AIM (Medical Policy #099 and #105). Medicare Advantage Part B Utilization Management (125)

New policy outlining associated Medicare Advantage Part B Medical Utilization Management for treatments requiring Prior Authorization.
Pharmacy Policy 033 – Med UM policy

Medical Utilization Management (MED UM) and Pharmacy Prior Authorization Policy Pharmacy Policy 034 - MED UM Drug List

Medications requiring prior authorization when covered under the members medical benefits and administered in a clinician’s office, outpatient setting, or by the home infusion therapy provider
Carelon Quality Care Cancer Program (099) This document addresses oncology drug treatment regimens for individual patients, which may include cytotoxic chemotherapy, biologic agents, immunotherapy, and other targeted therapies used to treat cancer. Effective 7/1/2021.
Carelon Medical Benefits Management Program Policies: Carelon (formerly AIM) Advanced Imaging/Radiology – Medical Policy #968 Carelon (formerly AIM) Genetic Testing Management Program – Medical Policy #954 Carelon (formerly AIM) Genetic Testing Management Program CPT and HCPCS Codes – Medical Policy

957

Carelon (formerly AIM) Quality Care Cancer Program (Radiation Oncology) – Medical Policy #937

For questions: ebr@bcbsma.com