CommercialCoverageHigh impact
[New York] Medical Policy and Clinical Guideline updates
Anthem BCBS·NY · Gastroenterology, Cardiology, Bariatric Surgery +2 more·Medical Policy
Effective date
May 1, 2026
We identified it
May 18, 2026
Summary
Anthem Blue Cross and Blue Shield has revised 3 medical policies and 3 clinical guidelines effective May 1, 2026, which may result in services previously covered now being classified as not medically necessary and/or investigational. Affected areas include IBS biomarker testing, Alzheimer's disease biomarker testing, transcatheter heart valve procedures, neonatal care levels, upper GI endoscopy, and bariatric surgery. Billing teams must review each policy detail to identify which claims may now require prior authorization or face denial.
Action Required
By April 30, 2026: Billing team and clinical staff must access the full revised policies at https://www.anthembluecross.com/ny/provider (Resources > Medical Policies & Clinical UM Guidelines) for the following policies: LAB.00037, LAB.00046, SURG.00121, CG-MED-26, CG-MED-59, and CG-SURG-83. Review each policy to identify specific CPT/HCPCS codes affected. Update billing system rules to flag these services for medical necessity review and/or prior authorization requirements. Notify clinical staff of documentation requirements for these six policies. Beginning May 1, 2026, deny or request additional documentation for any claims for these services that do not meet the revised medical necessity criteria. Do NOT reprocess claims submitted before May 1, 2026 under the new policy rules.