Medicare AdvantageCoverageHigh impact
[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·NY · Radiology, Oncology, Radiation Oncology +4 more·Provider Bulletin
Effective date
Apr 4, 2026
We identified it
May 18, 2026
Summary
Carelon Medical Benefits Management updated clinical appropriateness guidelines effective April 4, 2026 across radiology, oncologic imaging, radiation oncology, genetic testing, and rehabilitative services for Medicare Advantage and Medicaid plans. Changes include removal of certain imaging requirements (pediatric SBO radiographs, sports hernia imaging), alignment with ACR and NCCN guidelines, expanded cancer screening and treatment indications, new hereditary cancer syndrome criteria, and addition of specific billing codes for genetic testing (81218, 81310, 81334, 81338, 81339, 81345).
Action Required
By April 4, 2026: (1) Billing team must update prior authorization rules in billing system to remove authorization requirements for pediatric SBO radiographs and sports hernia imaging; (2) Providers and billing staff must review radiology ordering guidelines—simplifications to hepatic fibrosis, adrenal mass, groin hernia, and abdominal/pelvic pain imaging to avoid unnecessary authorization requests; (3) Genetic testing team must implement new billing codes 81218, 81310, 81334, 81338, 81339, 81345 in system for hereditary cancer testing claims; (4) Oncology billing staff must update prior authorization criteria for expanded cancer screening (breast with increased density/atypia, lung screening operational changes, pancreatic/anal NCCN-aligned), diagnostic workup, and new radiation therapy indications (expanded lesion numbers, new SIRT for liver, expanded SBRT indications); (5) Encounter forms and EMR templates must be updated to reflect expanded genetic testing criteria (new syndromes, family history thresholds, autism spectrum disorder/macrocephaly for Cowden syndrome); (6) Staff should reference updated guidelines at Carelon's provider portal or guidelines email (MedicalBenefitsManagement.guidelines@Carelon.com) for real-time authorization processing. Failure to align with new guidelines by effective date will result in claim denials and delayed authorizations.