2025 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 62
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Page 62
- Hodgkin lymphoma
- Non-Hodgkin lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
- Osteosarcoma
- Plasma cell disorders (e.g., multiple myeloma, amyloidosis, plasma cell leukemia, POEMS - polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome)
- Wilms Tumor
Benefits for Blood or marrow stem cell transplants are available for the diagnoses below, only when performed as part of a clinical trial when a clinical trial for the diagnosis below is available in a Blue Distinction Center; and you meet the criteria for inclusion in the clinical trial and the requirements below.
- Allogeneic blood or marrow stem cell transplants for:
- Autoimmune - limited to: scleroderma/systemic sclerosis, systemic lupus erythematosus, CIDP – (chronic inflammatory demyelinating polyneuropathy), and Idiopathic (Juvenile) rheumatoid arthritis
- Breast cancer
- Germ Cell Tumors
- High-risk or relapsed neuroblastoma
- Lysosomal metabolic diseases: e.g., Mucopolysaccharidosis type II (Hunter syndrome); Mucopolysaccharidosis type IV (Morquio syndrome); Mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome), Fabry disease, Gaucher disease
- Renal cell carcinoma
- Sarcoma – Ewing sarcoma, rhabdomyosarcoma, soft tissue sarcoma
- Autologous blood or marrow stem cell transplants for:
- Autoimmune disease - e.g., systemic lupus erythematosus, CIDP (chronic inflammatory demyelinating polyneuropathy), Crohn's disease, Polymyositis-dermatomyositis, rheumatoid arthritis
- Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
- Sarcoma (e.g., rhabdomyosarcoma, soft tissue sarcoma)
- You must contact us at the customer service phone number listed on the back of your ID card to obtain prior approval (see Section 3); and
- The patient must be properly and lawfully registered in the clinical trial, meeting all the eligibility requirements of the trial; and
- For the transplant procedures listed above, the clinical trial must be reviewed and approved by the Institutional Review Board for the Blue Distinction Center for Transplant program where the procedure is to be performed.
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.
A transplant clinical trial may not be available for your condition, or 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 us at the phone number on the back of your ID card for assistance in determining if a covered clinical trial is available in a covered facility.