Medicare AdvantagePrior AuthHigh impact
[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·VA · Dermatology, Bariatric Surgery, General Surgery +8 more·Prior Authorization
Effective date
May 14, 2026
We identified it
May 20, 2026
Summary
Anthem Virginia has updated multiple medical policies and clinical utilization management guidelines effective May 14, 2026, affecting prior authorization requirements, coverage criteria, and medical necessity determinations across various service categories including gene therapy, durable medical equipment, surgical procedures, and diagnostic testing. Some services previously covered may now be found not medically necessary under revised criteria. All affected policies must be reviewed and implemented in billing workflows before the effective date.
Action Required
By May 14, 2026: (1) Billing team must obtain and review all revised Medical Policies and Clinical UM Guidelines listed in the update from Anthem's Medical Policies & Clinical UM Guidelines website. (2) Update prior authorization protocols in billing system for revised policies: ANC.00007 (skin services), DME.00011 (electrical stimulation), LAB.00019 (liver fibrosis tests), MED.00129 (spinal muscular atrophy gene therapy), MED.00161 (Wiskott-Aldrich gene therapy), SURG.00129 (sleep apnea surgery), and TRANS.00009 (lung transplant). (3) Implement new Clinical UM Guidelines: CG-ANC-04, CG-DME-24, CG-DME-33, CG-DME-34, CG-DME-37, CG-LAB-36, CG-MED-103, CG-MED-104, CG-MED-105, CG-MED-26, CG-SURG-130, and CG-SURG-83 into authorization workflows. (4) Train all billing, authorization, and clinical staff on changed medical necessity criteria and coverage position changes. (5) Notify providers of policy changes that may affect claims previously submitted. (6) Update encounter forms and EMR templates to reflect new authorization requirements. Failure to implement changes before May 14, 2026 will result in claim denials for services not meeting updated medical necessity criteria.