[Virginia] Carelon Medical Benefits Management Clinical Appropriateness Guidelines updates
Effective date
Nov 15, 2026
Identified
Aug 2, 2026
Summary
Carelon Medical Benefits Management updated its clinical appropriateness guidelines for Anthem Medicare Advantage plans in Virginia, effective for dates of service on and after November 15, 2026. Genetic testing changes require that all components of a test demonstrate clinical utility, add imlunestrant to the therapies for which ESR1 mutation testing is considered medically necessary, and state that testing for breast cancer recurrence is not medically necessary. Orthopedic changes standardize conservative management to 12 weeks across procedures, with an allowance for shorter duration for severe ADL impacts, and exclude Kellgren-Lawrence grade 4 osteoarthritis from shoulder, hip and knee arthroscopy.
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01Effective for dates of service on and after November 15, 2026: Ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management at providerportal.com, which the source describes as the fastest way to request authorization.
02Do not bill whole exome, whole genome or whole transcriptome analysis as medically necessary, because the guidelines consider them not medically necessary.
03Before billing shoulder arthroplasty, shoulder arthroscopy, meniscal allograft transplantation or osteochondral grafts, confirm 12 weeks of conservative management and/or symptoms.
04Send guideline questions to MedicalBenefitsManagementguidelines@carelon.com.
Original notice
[Virginia] Carelon Medical Benefits Management Clinical Appropriateness Guidelines updates
providernews.anthem.com · Always check the source before changing claims.
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