Medicare AdvantageCoverageHigh impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines effective
Anthem BCBS·VA · Radiology, Cardiology, Vascular Surgery +1 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 (radiology, vascular, cardiac), cardiology procedures, and cardiac devices. Changes include expanded indications for advanced imaging (CT, CTA, MRA, PET), modified pre/post-operative imaging requirements, alignment with updated professional society guidelines, and clarified criteria for percutaneous coronary intervention and implantable cardiac devices. Billing teams must review affected departments' protocols and ensure prior authorization requests align with new clinical criteria.
Action Required
By September 19, 2026: (1) Radiology/Imaging team: Update prior authorization protocols for brain CT perfusion, extremity imaging (osteomyelitis, TFCC, meniscal tears, knee arthroplasty), spine imaging, and vascular imaging per expanded/modified indications. Remove syncope as indication for advanced vascular imaging. (2) Cardiology team: Update prior authorization criteria for diagnostic coronary angiography and PCI to reflect removal of non-culprit lesion criteria post-STEMI and alignment with ESC 2024 guidelines for left main disease complexity assessment. Add hypertrophic cardiomyopathy indications per Ommen et al. 2024. (3) Cardiac Device team: Update criteria for wearable cardioverter defibrillators to include non-ischemic cardiomyopathy in early treatment stages; update ICD and pacemaker criteria per Russo AM et al. 2025 appropriate use criteria; update dual-chamber leadless pacemaker criteria. (4) All clinical staff: Document medical necessity per new clinical criteria in EMR templates and encounter forms. (5) Billing system: Configure prior auth rules in billing software to reflect new/removed indications. Failure to align with updated criteria may result in claim denials for lack of medical necessity or authorization mismatches.