2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 67
 
Benefits for Autologous blood or marrow stem cell transplants are only available for the diagnoses as indicated below:
 
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
     
  • Central nervous system (CNS) embryonal tumors (e.g., atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumors (PNETs), medulloblastoma, pineoblastoma, ependymoblastoma)
     
  • Ewing’s sarcoma
     
  • Germ cell tumors (e.g., testicular germ cell tumors)
     
  • High-risk neuroblastoma
     
  • Hodgkin’s lymphoma
     
  • Non-Hodgkin’s lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
     
  • Plasma cell disorders (e.g., multiple myeloma, amyloidosis, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome)
     
  • Scleroderma

Notes:
 
  • See page 65 for the prior approval and facility transplant program requirements that apply to blood or marrow stem cell transplants.
     
  • See below and page 68 for information about blood or marrow stem cell transplants covered only in clinical trials.
 
Clinical Trials:

Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. A clinical trial has possible benefits as well as risks. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the trial, and the beginning and end points of the trial. Information regarding clinical trials is available at www.cancer.gov/about-cancer/treatment/clinical-trials.

Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials or there may not be any trials available in a Blue Distinction Center for Transplants to treat your condition at the time you seek to be included in a clinical trial. If your physician has recommended you participate in a clinical trial, we encourage you to contact the Case Management Department at your Local Plan for assistance.

Transplants that may be eligible for clinical trials:

Benefits for Blood or marrow stem cell transplants are available for the diagnoses below, only when performed as part of a clinical trial that meets the transplant program prior approval criteria described on page 66 and the requirements listed below, when a clinical trial for the diagnosis is available in a Blue Distinction Center; and you meet the criteria for inclusion in the clinical trial:

 
  • Allogeneic blood or marrow stem cell transplants for:
     
    • Breast cancer
       
    • Colon cancer
       
    • Epidermolysis bullosa
       
    • Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
       
    • Ovarian cancer
       
    • Prostate cancer
       
    • Renal cell carcinoma
       
    • Retinoblastoma
       
    • Rhabdomyosarcoma
       
    • Sarcoma
       
    • Wilm’s tumor