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[New York] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Effective date
Nov 15, 2026
Identified
Aug 18, 2026
Summary
Effective for dates of service on and after Nov. 15, 2026, Carelon's clinical appropriateness guidelines change for Medicaid members in New York. Genetic testing guidelines add a requirement that all components of a test must demonstrate clinical utility, and whole exome, whole genome and whole transcriptome analysis are considered not medically necessary. For joint surgery, the required conservative management duration is standardized to 12 weeks across procedures, and new criteria cover electrical and ultrasound bone growth stimulation devices for conditions of the appendicular skeleton.
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What to do
Action · 7 steps
01By Nov.
0215, 2026: Apply the updated Carelon criteria to dates of service on and after this date.
03Billing team: For shoulder arthroplasty, shoulder arthroscopy, meniscal allograft transplantation and osteochondral grafts, confirm 12 weeks of conservative management and/or symptoms.
04For shoulder, hip and knee arthroplasty, confirm 12 weeks from any arthroscopy procedure performed before the arthroplasty.
05Shoulder, hip and knee arthroscopy criteria now exclude Kellgren-Lawrence grade 4 osteoarthritis.
06For genetic testing, confirm that all components of the test demonstrate clinical utility.
07Ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management through the provider portal at www.providerportal.com, and guideline questions go to MedicalBenefitsManagement.guidelines@carelon.com.
Original notice
[New York] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
providernews.anthem.com · Always check the source before changing claims.
Related changes
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