CommercialCoverageHigh impact
[New York] Medical Policy and Clinical Guideline updates effective
Anthem BCBS·NY · Oncology, Neurology, Neurosurgery +4 more·Medical Policy
Effective date
Oct 1, 2026
We identified it
Jul 2, 2026
Summary
Anthem has issued new and revised medical policies and clinical guidelines effective October 1, 2026, affecting coverage determinations for specific procedures including intrabuccal radiofrequency devices for cancer, mucosal integrity testing, Alzheimer's biomarker testing, gene therapy for beta thalassemia, deep brain stimulation, inhaled nitric oxide, and cochlear implants. Previously covered services may now be determined as not medically necessary or investigational, requiring billing teams to verify coverage before claim submission.
Action Required
By September 15, 2026: Billing team must obtain and review complete policy documents for the following Anthem policies effective October 1, 2026: DME.00056, MED.00166, LAB.00046, MED.00140, SURG.00026, CG-MED-69, and CG-SURG-81. Update billing system to flag claims for these services for manual review and prior authorization verification before submission. Coordinate with clinical staff and providers to ensure all submitted claims include documentation of medical necessity. Communicate with patients that coverage determinations may change, and some previously covered services may require additional authorization. Failure to obtain prior authorization will result in claim denials. Reference the complete policies at https://www.anthem.com (Commercial) or https://www.fepblue.org (FEP) to identify specific CPT/HCPCS codes affected by these policy changes.