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Anthem BCBSCommercial · Prior Auth · Provider Bulletin · OH · Orthopedics, Cardiology, Vascular Surgery +5 moreHigh impact

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

Effective date
Nov 15, 2026
Identified
Aug 12, 2026

Summary

Effective for dates of service on and after November 15, 2026, the Carelon Medical Benefits Management Clinical Appropriateness Guidelines are updated for Anthem Blue Cross and Blue Shield commercial plans in Ohio. The updates cover vascular embolization, varicose vein treatment, PFO closure, genetic and liquid biopsy testing, joint surgery, hypoglossal nerve stimulators and upper GI endoscopy. For upper endoscopy, EGD for new-onset dyspepsia is medically necessary in patients 55 or older rather than 50 or older, and EGD for weight loss requires a loss of 5% or more of usual body weight over the past 12 months. For joint surgery, conservative management is standardized to 12 weeks across procedures, with a shorter allowance for severe ADL impacts, and shoulder, hip and knee arthroscopy adds an exclusion for Kellgren-Lawrence grade 4 osteoarthritis.

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What to do

Action · 4 steps
01Effective for dates of service on and after November 15, 2026: For shoulder, hip and knee arthroscopy, conservative management must last 12 weeks, with a shorter allowance for severe ADL impacts.
02Shoulder, hip and knee arthroplasty requires 12 weeks from the arthroscopy procedure before arthroplasty, and shoulder, hip and knee arthroscopy has an exclusion for Kellgren-Lawrence grade 4 osteoarthritis.
03For upper endoscopy, EGD for new-onset dyspepsia is medically necessary in patients 55 or older rather than 50 or older, and EGD for nausea or vomiting requires a duration of 7 days or more unless the patient has a first-degree relative with upper GI malignancy.
04Submit prior authorization requests through Carelon's provider portal at providerportal.com, the fastest and most convenient way to request authorization.

Original notice

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

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[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness GuidelinesHighEffective Nov 15, 2026 · Provider Bulletin[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness GuidelinesHighEffective Nov 15, 2026 · Provider Bulletin[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness GuidelinesMediumEffective Nov 15, 2026 · Provider Bulletin[Ohio] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines effectiveMediumEffective Sep 19, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list

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