[California] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines effective

By September 19, 2026: (1) Billing and authorization teams must update prior authorization policies and criteria in billing/EMR systems to reflect expanded indications for: brain CT perfusion, extremity imaging (osteomyelitis, TFCC instability, meniscal tears, knee arthroplasty presurgical), spine imaging (spinal infection, axial spondyloarthropathy), vascular imaging including new CTA head/neck codes, duplex ultrasound for carotid/vascular disease, cardiac CT for CAC scoring, cardiac MRI, PET myocardial imaging, and coronary angiography/PCI criteria. (2) Update internal authorization templates to remove prior indications that were deleted: advanced vascular imaging for syncope, carotid imaging in syncope, and PCI for non-culprit lesions post-STEMI. (3) Adjust medication requirement thresholds for renal artery stenosis imaging from 4 to 3 antihypertensive medications. (4) Implement new surveillance intervals for post-revascularization imaging in vascular cases and post-thoracic aortic repair. (5) Providers and billing staff must be trained on new criteria for wearable cardioverter defibrillators (now including non-ischemic cardiomyopathy in early GDMT stages). (6) Update billing system rules to recognize consolidated cardiac device guidelines (CRT/ICD/pacemaker combined into single policy). Failure to implement these changes by effective date will result in claims being denied or delayed for lack of proper authorization documentation.