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

By September 19, 2026: Billing and clinical review teams must update Carelon prior authorization rules and clinical decision support in billing software to reflect all guideline changes. SPECIFIC ACTIONS: (1) Radiology team: Update CT brain perfusion indications; modify spine pain/radiculopathy frequency limits; update meniscal tear and knee arthroplasty imaging protocols. (2) Vascular imaging: Implement duplex ultrasound requirement BEFORE CTA/MRA for stroke/TIA symptoms present >30 days; add new indications for duplex (giant cell arteritis, carotid screening in asymptomatic high-risk patients, traumatic vascular injury, subclavian steal syndrome, vasculitis, pelvic venous disease, arterial entrapment syndrome, aneurysm/dilation). Remove syncope as indication for carotid imaging. (3) Cardiology: Remove prior authorization criteria for non-culprit PCI/angiography after STEMI; add new indications for coronary angiography (spasm, microvascular disease, hypertrophic cardiomyopathy per 2024 guidelines); expand cardiac MRI criteria for cardiomyopathy; expand wearable cardioverter defibrillator criteria to non-ischemic cardiomyopathy; update pacemaker criteria to include dual-chamber leadless options. (4) For renal artery stenosis imaging: Reduce required antihypertensive medications from four to three. Update prior authorization templates, encounter forms, and provider education materials. CONSEQUENCES: Claims submitted without alignment to updated guidelines will be subject to clinical review delays or denials. Providers who continue using removed indications will experience prior authorization denials.