[California] Medical Policies and Clinical Utilization Management Guidelines update

By April 1, 2026: Billing team must obtain and review detailed guidelines for all 16 updated policies on Anthem's Medical Policies & Clinical UM Guidelines website (link provided in source). For each policy affecting your practice's common procedures, determine: (1) which services require new or modified prior authorizations; (2) which services have new medical necessity criteria; (3) which previously covered services may now be denied. Update billing software rules, EMR templates, and provider encounter forms accordingly. Route specific policy changes to relevant departments (e.g., DME coordinators for CG-DME guidelines, surgical schedulers for SURG policies, lab managers for CG-LAB-11). Before April 12, 2026: Train billing and clinical staff on any changes affecting claim submission workflows. Affected services include: wound healing/soft tissue grafting (SURG.00011), transcatheter heart valves (SURG.00121), gene therapy for epidermolysis bullosa (SURG.00163), histotripsy (SURG.00165), stem cell transplantation (TRANS.00024), pressure-reducing support surfaces (CG-DME-16), powered wheeled mobility devices (CG-DME-31), UV light therapy devices (CG-DME-41), spinal unloading devices (CG-DME-59), vitamin D testing (CG-LAB-11), inhaled nitric oxide (CG-MED-69), transvaginal ultrasound (CG-RAD-30), 3-D imaging rendering (CG-RAD-31), bone mineral density testing (CG-RAD-32), tumor ablation (CG-SURG-61), implantable infusion pumps (CG-SURG-79), and sacral nerve stimulation (CG-SURG-95). Claims submitted without compliance to updated criteria will be denied.