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Anthem BCBSMedicaid · Coverage · Provider Bulletin · VA · Sleep Medicine, ENT (Ear, Nose & Throat), NeurologyMedium impact

[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

Act
by Nov 15, 2026
Effective date
Nov 15, 2026
Identified
Aug 11, 2026

Summary

Carelon Medical Benefits Management has added an exclusion for bilateral hypoglossal nerve stimulators in the treatment of obstructive sleep apnea, effective November 15, 2026. Providers must now obtain prior authorization for any hypoglossal nerve stimulator procedures and ensure unilateral (single-sided) implants only for Medicaid coverage under HealthKeepers, Inc. and Anthem HealthKeepers Plus in Virginia.

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What to do

by Nov 15, 2026 · 6 steps
01Billing team must update prior authorization workflows to flag and deny claims for bilateral hypoglossal nerve stimulator implants.
02Update encounter forms and provider education materials to specify that only unilateral hypoglossal nerve stimulator procedures are covered for Medicaid beneficiaries in Virginia.
03Providers must verify nerve stimulator laterality (unilateral vs. bilateral) at the point of authorization.
04Claims submitted for bilateral procedures will be denied.
05Contact providers in sleep medicine, otolaryngology, and neurology specialties with updated guidance.
06Prior authorization requests must be submitted through Carelon's provider portal at www.providerportal.com.

Original notice

[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
providernews.anthem.com · Always check the source before changing claims.
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Related changes

See all Anthem BCBS changes →
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness GuidelinesMediumEffective Nov 15, 2026 · Provider Bulletin[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness GuidelinesMediumEffective Sep 19, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list

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Anthem BCBS policiesVA policy changesSleep MedicineENT (Ear, Nose & Throat)Neurology

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