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[New York] Medical Policy and Clinical Guideline updates
Act
by Dec 1, 2026
Effective date
Jan 1, 2027
Identified
Jul 31, 2026
Summary
Anthem Blue Cross and Blue Shield is implementing two new clinical guidelines effective January 1, 2027: CG-MED-102 for dichoptic digital therapy for amblyopia and CG-SURG-116 for surgical treatment of hyperhidrosis. These guidelines establish medical necessity criteria that may result in services previously covered being designated as not medically necessary, potentially leading to claim denials.
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What to do
by Dec 1, 2026 · 5 steps
01Billing team and providers must obtain and review the full text of guidelines CG-MED-102 and CG-SURG-116 from https://anthem.com/provider (Select For Providers > your state > Resources > Medical Policies & Clinical UM Guidelines).
02Identify all current claims and encounters involving dichoptic digital therapy devices for amblyopia or endoscopic thoracic sympathectomy for hyperhidrosis.
03Educate providers on new medical necessity criteria for these services.
04Update encounter documentation templates and prior authorization processes to align with new criteria.
05Beginning January 1, 2027, ensure all claims for these services include documentation supporting medical necessity per the new guidelines.
If missed: Failure to meet the new criteria will result in claim denials and potential recoupment of previously paid claims.
Original notice
[New York] Medical Policy and Clinical Guideline updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
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