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Anthem BCBSMedicare Advantage · Coverage · Provider Bulletin · GA · Radiology, Oncology, Radiation Oncology +4 moreMedium impact

[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Act
by Apr 4, 2026
Effective date
Apr 4, 2026
Identified
May 18, 2026

Summary

Carelon Medical Benefits Management updated clinical appropriateness guidelines effective April 4, 2026, affecting radiology imaging protocols, oncologic imaging, radiation oncology, genetic testing, and rehabilitative services for Medicare Advantage plans in Georgia. Changes include alignment with ACR and NCCN criteria, removal of certain indications (e.g., sports hernia imaging), expanded cancer screening/treatment criteria, new genetic testing indications, and clarification of specific imaging requirements. Billing teams must review updates to prior authorization requirements and ensure documentation aligns with new clinical criteria.

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What to do

by Apr 4, 2026 · 7 steps
01Billing and clinical teams must review the comprehensive Carelon guideline updates across radiology, oncology, radiation oncology, genetic testing, and rehabilitation services.
02Update prior authorization protocols in billing system to remove imaging requirements for sports hernia and reflect new allowances (e.g., groin hernia post-nondiagnostic ultrasound, bariatric procedure-related imaging).
03Ensure genetic testing claims use the new CPT codes (81218, 81310, 81334, 81338, 81339, 81345) and verify new indications are documented (e.g., cribriform-morular thyroid cancer, GI cancers under age 50, expanded family history criteria for Lynch syndrome).
04Update radiation oncology authorization criteria to reflect expanded indications for SBRT, expanded CNS lesion counts, new SIRT coverage for liver cancer, and prostate cancer PSMA PET updates.
05Modify encounter templates and clinical documentation requirements to align with ACR/NCCN criteria changes.
06Train providers on removed/restricted indications to prevent claim denials (e.g., sports hernia imaging, IMRT on MRI-linear accelerator).
07Access updated guidelines at providerportal.com or contact MedicalBenefitsManagement.guidelines@Carelon.com for clarification.
If missed: Failure to implement changes may result in claim denials or delays for services no longer aligned with updated criteria.

Codes mentioned

812188131081334813388133981345

Original notice

[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
providernews.anthem.com · Always check the source before changing claims.
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Related changes

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[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness GuidelinesHighEffective Apr 4, 2026 · Provider Bulletin[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness GuidelinesMediumEffective Apr 4, 2026 · Provider Bulletin[Virginia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness GuidelinesHighEffective Apr 4, 2026 · Provider Bulletin[California] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness GuidelinesHighEffective Apr 4, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list

Related policy hubs

Anthem BCBS policiesGA policy changesRadiologyOncologyRadiation OncologyGeneticsPhysical TherapyOccupational TherapySpeech TherapyCode 81218Code 81310Code 81334Code 81338Code 81339Code 81345

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