Medicare AdvantagePrior AuthHigh impact
[New York] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines effective
Anthem BCBS·NY · Radiology, Cardiology, Vascular Surgery +2 more·Provider Bulletin
Effective date
Sep 19, 2026
We identified it
Jun 13, 2026
Summary
Carelon Medical Benefits Management updated clinical appropriateness guidelines effective September 19, 2026, affecting imaging authorization criteria across radiology, vascular, and cardiology specialties. Changes include expanded indications for advanced imaging (CT, CTA, MRI, PET), removed indications for certain procedures (e.g., advanced vascular imaging for syncope), modified pre- and post-operative imaging requirements, and updated cardiac device implantation criteria. Billing teams must review prior authorization rules and update system protocols to reflect new/removed indications and modified frequency limitations.
Action Required
By September 19, 2026: Billing and prior authorization teams must update Carelon prior authorization protocols in the billing system to reflect all guideline changes. SPECIFIC ACTIONS: (1) Radiology team—update CT brain/perfusion, extremity imaging, meniscal tear, knee arthroplasty, and spine imaging authorization rules per new indications and frequency limitations; (2) Vascular/Cardiology team—add new indications (e.g., PET/CT for vasculitis, CTA for aneurysm/AVM/dissection/FMD/pulsatile tinnitus, duplex for giant cell arteritis, subclavian steal syndrome), remove discontinued indications (syncope-related advanced vascular imaging), and update surveillance intervals for post-revascularization imaging; (3) Cardiology team—update criteria for diagnostic coronary angiography (remove STEMI non-culprit stenosis indication, add hypertrophic cardiomyopathy criteria), update PCI authorization rules (remove STEMI criteria, align with ESC 2024 for LM disease), and modify wearable cardioverter defibrillator (WCD) and cardiac device implantation criteria; (4) Update EMR/billing system templates to reflect revised prior authorization requirements; (5) Communicate changes to providers to ensure accurate documentation of medical necessity. Failure to update authorization protocols will result in claim denials for procedures that no longer meet guidelines or delays in authorization for newly approved indications.