MedicaidCoverageHigh impact
[New York] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·NY · Dermatology, Plastic Surgery, Orthopedics +8 more·Prior Authorization
Effective date
Jun 19, 2026
We identified it
May 27, 2026
Summary
Anthem Medicaid in New York is updating multiple medical policies and clinical utilization management guidelines effective June 19, 2026. These revisions affect prior authorization requirements, coverage criteria, and medical necessity determinations across diverse service categories including gene therapy, cosmetic/reconstructive services, durable medical equipment, transplantation, bariatric surgery, and sleep testing. Some previously covered services may now be found not medically necessary under the revised criteria.
Action Required
By June 1, 2026: Billing team and clinical staff must obtain and review the full policy text for each of the 16 affected medical policies and clinical UM guidelines on Anthem's Medical Policies & Clinical UM Guidelines website. Identify which services your practice provides and map them to the revised policies. Update prior authorization workflows, billing system rules, and clinical documentation templates accordingly. Key areas requiring review: (1) Cosmetic and Reconstructive Services - Skin Related (ANC.00007); (2) Electrical Stimulation devices (DME.00011); (3) Liver fibrosis testing (LAB.00019); (4) Gene therapy for spinal muscular atrophy (MED.00129) and Wiskott-Aldrich syndrome (MED.00161); (5) Sleep apnea surgery (SURG.00129); (6) Lung transplantation (TRANS.00009); (7) Manual wheelchairs and accessories (CG-DME-24, CG-DME-33, CG-DME-34); (8) Hearing aids (CG-DME-37); (9) Sleep testing (CG-MED-105); (10) Bariatric surgery (CG-SURG-83); and other listed guidelines. Contact Anthem at the provider relations number on your fee schedule if clarification is needed on coverage changes. Document all policy changes in your compliance file. Failure to follow revised medical necessity criteria will result in claim denials and potential recoupment of non-compliant claims paid after the effective date.