All PlansCoverageHigh impact
Medical Policy and Coding Updates - June 2026
Premera Blue Cross·WA · Radiology, Cardiology, Orthopedics +5 more·Medical Policy
Effective date
Sep 19, 2026
We identified it
Jun 16, 2026
Summary
Carelon Medical Benefits Management has updated clinical appropriateness guidelines for radiology, sleep disorder management, and genetic testing, expanding coverage criteria for many imaging studies and diagnostic tests. Multiple policies also updated medical necessity criteria for procedures like negative pressure wound therapy and orthognathic surgery.
Action Required
By September 19, 2026: Billing and prior authorization teams must review and update internal guidelines to align with new Carelon appropriateness criteria. Key changes include expanded CT cerebral perfusion indications, new allowances for extremity imaging without repeat x-rays for osteomyelitis, updated cardiac imaging criteria, and modified genetic testing requirements. Contact Carelon at MedicalBenefitsManagement.guidelines@Carelon.com for specific guideline documentation. Update prior authorization workflows to reflect new coverage criteria to prevent claim denials.