MedicaidPrior AuthHigh impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Anthem BCBS·VA · Radiology, Cardiology, Sleep Medicine +2 more·Provider Bulletin
Effective date
Sep 19, 2026
We identified it
May 28, 2026
Summary
Carelon Medical Benefits Management has updated clinical appropriateness guidelines for Virginia Medicaid effective September 19, 2026, affecting imaging authorization requirements across radiology, cardiology, and sleep medicine. Changes include expanded indications for brain CT, vascular imaging, and cardiac procedures; removal of certain non-culprit vessel interventions post-STEMI; updated sleep apnea testing criteria; and alignment with 2024-2025 professional society guidelines. Billing teams must update prior authorization workflows and documentation requirements for affected imaging and procedural codes.
Action Required
By September 19, 2026: (1) Billing and prior authorization teams must update Carelon authorization system to reflect all guideline changes across radiology (brain CT, extremity imaging, spine imaging, vascular imaging), cardiology (diagnostic coronary angiography, PCI, cardiac CT/MRI), and sleep medicine (polysomnography, home sleep apnea testing, hypoglossal nerve stimulation). (2) For radiology: Remove prior auth requirement for repeat X-rays in osteomyelitis/avascular necrosis management; add authorization pathways for expanded brain CT perfusion indications, TFCC instability imaging without conservative management requirement, and new vascular imaging indications (PET/CT for vasculitis, CTA head/neck for aneurysm/AVM/dissection). (3) For cardiology: Remove prior auth for PCI of non-culprit vessels post-STEMI; add authorization for diagnostic coronary angiography for coronary spasm/microvascular disease and hypertrophic cardiomyopathy; expand PCI criteria for complex disease per ESC 2024 guidelines; implement 5-10 year repeat interval for CAC score zero studies. (4) For sleep medicine: Update authorization criteria to remove RDI definition, align home sleep apnea testing with AASM 2025 guidelines, add in-lab study criteria for nocturnal seizures in patients age 17 and under, expand contraindications to home testing, and add hypoglossal nerve stimulation contraindications for Down syndrome patients. (5) Providers should submit all prior authorization requests via Carelon's provider portal (24/7 access). (6) Contact medicalbenefitsmanagement.guidelines@carelon.com for guideline clarifications. Claims submitted without adherence to updated authorization requirements will be denied.