[New York] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

Before November 15, 2026: (1) Billing and Prior Authorization team must review and update all prior auth criteria in the system for genetic testing orders to reflect new medical necessity requirements, including new drug indicators (imlunestrant, niraparib, talazoparib) and expanded cancer stage indications. (2) Update clinical decision support rules to deny/flag orders for testing explicitly noted as NOT medically necessary (e.g., WES/WGS/WTA, NIFTP somatic testing, ctHPV in oropharyngeal carcinoma). (3) For orthopedic procedures: Billing team must update system rules to require 12-week documented conservative management duration (or shorter if severe ADL impact) PRIOR to approval of shoulder/hip/knee arthroplasty, arthroscopy, and small joint surgery. Update encounter templates and prior auth forms to capture conservative management dates. (4) Providers must document which specific therapy (with new drug names) testing supports; claims lacking therapy documentation may be denied. (5) Specimen handlers and lab liaisons must understand new requirements for multigene panel components to demonstrate clinical utility. Failure to implement these changes will result in claim denials for non-compliant orders.