CommercialPrior AuthMedium impact
[Ohio] Medical Policies and Clinical UM Guidelines
Anthem BCBS·OH, IN, KY, MO, WI · Bariatric Surgery, General Surgery·Provider Bulletin
Effective date
Aug 1, 2026
We identified it
May 29, 2026
Summary
Anthem Blue Cross and Blue Shield updated medical policies and clinical utilization management guidelines effective August 1, 2026, for Ohio, Indiana, Kentucky, Missouri, and Wisconsin. Changes include a new gene therapy policy for Wiskott-Aldrich Syndrome (requiring prior authorization) and revisions to bariatric surgery coverage guidelines, adding three new endoscopic procedures to the medically necessary list and moving vertical banded gastroplasty to non-medically necessary.
Action Required
By July 15, 2026: Billing team must review updated bariatric surgery policy (CG-SURG-83) and update billing system to recognize endoscopic sleeve gastroplasty, SADI-S, and duodenal jejunal bypass with gastric sleeve (DJB-SG) as medically necessary procedures requiring prior authorization. Reclassify vertical banded gastroplasty as non-medically necessary in billing software and encounter forms. Additionally, flag gene therapy claims for Wiskott-Aldrich Syndrome (Waskyra infusion) as requiring prior authorization through Carelon Medical Benefits Management. Update provider documentation templates and prior authorization submission processes. Coordinate with clinical staff to ensure proper documentation for bariatric procedure medical necessity determinations. Failure to obtain required prior authorizations will result in claim denials.