Medicare AdvantageCoverageHigh impact
[Virginia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·VA · Radiology, Oncology, Radiation Oncology +9 more·Provider Bulletin
Effective date
Apr 4, 2026
We identified it
May 18, 2026
Summary
Carelon Medical Benefits Management has updated clinical appropriateness guidelines for Virginia Medicare Advantage members, effective April 4, 2026. Changes include simplified imaging criteria across radiology, oncology, and genetics testing; expanded coverage for advanced cancer treatments and genetic testing; and clarifications for radiation therapy, theranostics, and rehabilitative services. Billing and clinical teams must review updates in their respective specialty areas and ensure prior authorization requests reflect new guidelines.
Action Required
By April 3, 2026: (1) Billing team must update prior authorization workflows and criteria in billing software to reflect all guideline changes, particularly for imaging, oncology, radiation therapy, and genetic testing services. (2) Providers must review updated clinical criteria for their specialties and update documentation templates and order entry forms accordingly. (3) For genetic testing (CPT codes 81218, 81310, 81334, 81338, 81339, 81345), update order validation rules to reflect expanded testing criteria for hereditary cancer syndromes, including new indications for adenomatous polyp syndromes, PTEN-hamartoma syndrome variants, Lynch syndrome (second and third-degree relatives), hereditary diffuse gastric cancer, and new sections for hereditary myeloid neoplasms and brain tumors. (4) For oncology and radiation therapy services, update prior auth criteria to reflect expanded SBRT indications, new PSMA PET/theranostics protocols, and revised treatment specifications. (5) For imaging orders, implement simplified criteria (removal of redundant requirements, ACR/NCCN alignment, removal of sports hernia indication, revised pediatric SBO protocols). (6) Front-line staff should be trained on new guidelines prior to effective date. Failure to update workflows may result in claim denials or inappropriate approvals. Access updated guidelines at providerportal.com or contact MedicalBenefitsManagement.guidelines@Carelon.com for clarification.