Medicare AdvantagePrior AuthHigh impact
[Ohio] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines effective
Anthem BCBS·OH · 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, across radiology, cardiology, and vascular imaging. Changes include expanded indications for brain CT perfusion, modified requirements for extremity and spine imaging, new vascular imaging criteria, and updated cardiac device placement guidelines. Prior authorization requirements and frequency limitations have been modified to align with current professional society guidelines.
Action Required
By September 19, 2026: Billing and clinical teams must review and implement changes to prior authorization workflows across multiple service lines. (1) Radiology team: Update imaging approval criteria for brain CT perfusion, extremity imaging (osteomyelitis, avascular necrosis, TFCC instability, meniscal tears, knee arthroplasty), and spine imaging; remove repeat X-ray requirements where noted; align frequency limitations with MSK guidelines. (2) Vascular imaging team: Implement new duplex ultrasound indications (giant cell arteritis, carotid screening in high-risk asymptomatic patients, traumatic vascular injury, subclavian steal syndrome, upper extremity vasculitis, arterial entrapment syndrome, aneurysms/dilations); add PET/CT for vasculitis; add CTA/MRA criteria for aneurysm, AVM, dissection, fibromuscular dysplasia, pulsatile tinnitus, procedure-related imaging, stenosis/occlusion, stroke evidence, and subclavian steal; remove syncope as an indication; reduce antihypertensive medication requirement from four to three for renal artery stenosis; align post-revascularization surveillance intervals across upper and lower extremities. (3) Cardiology team: Implement expanded cardiac MRI criteria for hypertrophic and noncompaction cardiomyopathy; clarify PET perfusion imaging language; remove PCI indication for STEMI with residual non-culprit stenosis; add coronary angiography for spasm/microvascular disease and hypertrophic cardiomyopathy; expand PCI criteria for left main disease with complex non-LM disease; expand wearable cardioverter defibrillator criteria to non-ischemic cardiomyopathy early treatment stages; expand dual-chamber leadless pacemaker criteria. (4) Update all prior authorization templates, decision support tools, and electronic health record documentation requirements in billing system. (5) Train billing staff, coders, and clinical staff on new criteria before effective date. Failure to update authorization workflows will result in claim denials and potential compliance issues.