CommercialPrior AuthMedium impact
Medical Policy and Coding Updates - August 2024
Premera Blue Cross·WA, AK · Radiology, Cardiology, Neurology +3 more·Medical Policy
Effective date
Oct 20, 2024
We identified it
Jun 16, 2026
Summary
Carelon Medical Benefits Management (formerly AIM Specialty Health) is updating clinical appropriateness guidelines across multiple specialties including radiology, cardiology, genetic testing, radiation oncology, and sleep medicine. The updates expand coverage criteria for certain procedures like Alzheimer's imaging, echocardiography monitoring, and genetic testing while restricting others.
Action Required
By October 20, 2024: Prior authorization teams must update Carelon/AIM Specialty Health request protocols for the following changes: 1) Brain MRI and amyloid PET imaging now covered for Alzheimer's patients considering lecanemab treatment, 2) Echocardiography frequency expanded for patients on mavacamten and transplant candidates, 3) Whole exome sequencing now covers early onset epilepsy before age 3, 4) Sleep study criteria updated with new contraindications for automatic PAP titration. Contact Carelon at MedicalBenefitsManagement.guidelines@Carelon.com for specific guideline questions. Review current authorization workflows to ensure compliance with updated clinical criteria.