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Medical Policy and Coding Updates - July 2025
Premera Blue Cross·WA, AK · Radiology, Oncology, Cardiology +3 more·Medical Policy
Effective date
Nov 15, 2025
We identified it
Jun 16, 2026
Summary
This policy updates Carelon MBM Clinical Appropriateness Guidelines for Radiology and Genetic Testing effective November 15, 2025. Key changes include expanded criteria for brain MRI, simplified extremity imaging requirements, updated cardiac imaging guidelines, and broadened genetic testing criteria for various cancers.
Action Required
By November 15, 2025: Billing team must review and update prior authorization processes for radiology services (brain MRI, extremity imaging, cardiac imaging) and genetic testing to align with new Carelon MBM guidelines. Update internal protocols for amyloid therapy monitoring MRI, extremity pain imaging thresholds, cardiac surgery imaging requirements, and expanded genetic testing criteria for cancer patients. Train staff on revised criteria to ensure proper authorization requests and reduce claim denials.