[New York] Carelon Medical Benefits Management Clinical Appropriateness Guidelines updates
Effective date
Nov 15, 2026
Identified
Aug 2, 2026
Summary
Effective for dates of service on and after November 15, 2026, updated Carelon Medical Benefits Management Clinical Appropriateness Guidelines apply to Medicare Advantage. Genetic and somatic tumor testing requires that all components of a test demonstrate clinical utility, and whole exome, whole genome and whole transcriptome analysis are considered not medically necessary. Joint procedures now require 12 weeks of conservative management with a shorter allowance for severe impact on daily activities, arthroscopy is excluded for Kellgren-Lawrence grade 4 osteoarthritis, and bilateral hypoglossal nerve stimulators are excluded for obstructive sleep apnea.
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01Before November 15, 2026: Billing team and ordering providers should confirm that genetic and tumor testing, joint surgery and hypoglossal nerve stimulator requests meet the updated criteria, including clinical utility for every component of a genetic test and the 12-week conservative management requirement for joint procedures.
02For shoulder, hip and knee arthroplasty, 12 weeks must pass from the arthroscopy procedure before the arthroplasty.
03Ordering and servicing providers may submit prior authorization requests at providerportal.com, which is available 24/7, and questions about the guidelines can be sent to MedicalBenefitsManagementguidelines@carelon.com.
Original notice
[New York] Carelon Medical Benefits Management Clinical Appropriateness Guidelines updates
providernews.anthem.com · Always check the source before changing claims.
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