MedicaidCoverageMedium impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Anthem BCBS·VA · Sleep Medicine, ENT (Ear, Nose & Throat), Neurology·Provider Bulletin
Effective date
Nov 15, 2026
We identified it
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.
Action Required
By November 15, 2026: Billing team must update prior authorization workflows to flag and deny claims for bilateral hypoglossal nerve stimulator implants. Update encounter forms and provider education materials to specify that only unilateral hypoglossal nerve stimulator procedures are covered for Medicaid beneficiaries in Virginia. Providers must verify nerve stimulator laterality (unilateral vs. bilateral) at the point of authorization. Claims submitted for bilateral procedures will be denied. Contact providers in sleep medicine, otolaryngology, and neurology specialties with updated guidance. Prior authorization requests must be submitted through Carelon's provider portal at www.providerportal.com.