[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

By October 15, 2026: (1) Billing team must audit current prior authorization protocols for vascular procedures (cardiovascular, endovascular revascularization, varicose vein treatments, vascular embolization, PFO closure) and oncology genetic testing to align with new Carelon guidelines. (2) Update EMR/billing system templates to reflect new medical necessity criteria, specifically: PFO closure not medically necessary for patients >60 years, varicose veins defined as ≥3mm diameter, repeat duplex required >3 months post-initial treatment, genicular artery embolization not medically necessary in all scenarios, and expanded genetic testing indications for breast, prostate, lung, thyroid, and other cancers. (3) Providers and billing staff must document performance status and hepatic burden for liver malignancy embolization cases. (4) Create prior authorization decision trees reflecting removed contraindications (e.g., thermal ablation for non-thermal ablation no longer a contraindication) and new inclusions (e.g., cyanoacrylate ablation for perforators, drug-eluting beads for liver tumors, varicocele embolization). (5) Review genetic testing orders to ensure all test components demonstrate clinical utility per new requirement. (6) Clinical staff must update patient education materials regarding PFO closure age cutoff (≤60 years) and RoPE score requirements. Claims submitted after November 15, 2026 without compliance to new guidelines will be subject to denial or medical necessity review delays.