Anthem BCBSMedicaid · Coverage · Provider Bulletin · VA · Radiology, Cardiology, Vascular Surgery +3 moreMedium impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Effective date
Sep 19, 2026
Identified
May 28, 2026
Summary
Carelon Medical Benefits Management updated its Clinical Appropriateness Guidelines for Anthem HealthKeepers Plus Medicaid products in Virginia, effective for dates of service on and after September 19, 2026. The imaging changes include expanded CT indications for cerebral perfusion, new allowances for the CTA head and neck code, and a requirement for duplex ultrasound before CTA or MRA for stroke or TIA symptoms present for more than 30 days. Knee arthroplasty presurgical imaging, spine pain and radiculopathy imaging, and vascular ultrasound criteria were also updated. Cardiology and sleep disorder criteria were updated as well, including new polysomnography and home sleep apnea testing rules.
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01Already effective September 19, 2026: Check current applicability of the updated Carelon criteria for the imaging, cardiology, and sleep services in the notice for Anthem HealthKeepers Plus Medicaid members.
02Ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management on the company's provider portal, which is available 24/7 to process orders in real time.
03Questions about the guidelines go to medicalbenefitsmanagement.guidelines@carelon.com.
Original notice
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
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