← Back to list
[New York] 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 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).
Get alerts when payers change rules like this one
We check Anthem BCBS and other payers every day and email you when a change matches your specialty and state.
Get Anthem BCBS alertsPolicy Monitoring is free. No card required.
What to do
by Apr 4, 2026 · 6 steps
01Billing team must update prior authorization rules in billing system to remove authorization requirements for pediatric SBO radiographs and sports hernia imaging.
02Providers 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.
03Genetic testing team must implement new billing codes 81218, 81310, 81334, 81338, 81339, 81345 in system for hereditary cancer testing claims.
04Oncology 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).
05Encounter 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).
06Staff should reference updated guidelines at Carelon's provider portal or guidelines email (MedicalBenefitsManagement.guidelines@Carelon.com) for real-time authorization processing.
If missed: Failure to align with new guidelines by effective date will result in claim denials and delayed authorizations.
Codes mentioned
812188131081334813388133981345
Original notice
[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[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[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness GuidelinesMediumEffective 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