Medicare AdvantagePrior AuthHigh impact
[California] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·CA · Cardiology, Cardiothoracic Surgery, Vascular Surgery +10 more·Prior Authorization
Effective date
Sep 28, 2026
We identified it
Aug 26, 2026
Summary
Anthem Blue Cross (California) has updated 24 Medical Policies and Clinical UM Guidelines effective September 28, 2026, affecting prior authorization and medical necessity criteria for procedures including cardiac devices, diabetes management devices, wound healing products, surgical procedures, and laboratory testing. Some previously covered services may now be classified as not medically necessary under the revised criteria. Billing teams must review affected guidelines and update prior authorization workflows accordingly.
Action Required
By September 28, 2026: (1) Billing and prior authorization teams must access the complete Medical Policies & Clinical UM Guidelines on Anthem's website to identify specific CPT/HCPCS codes affected by the 24 revised and new guidelines listed in this notice. (2) Update billing system prior authorization rules for the following guideline categories: cardiac procedures (PFO closure, mitral/tricuspid valve, aortic valve, LAA closure), diabetes management (CGM devices, automated insulin delivery), laboratory testing (iron, PT, lipid panel), surgical procedures (wound healing products, tibial nerve stimulation, Mohs surgery, venous angioplasty, GERD therapy), durable medical equipment (cardiac monitors, knee braces), and transplant services (cord blood, liver transplant). (3) Providers must document expanded medical necessity criteria per revised guidelines; update encounter templates and clinical documentation requirements. (4) Distribute this policy notice to all clinical and billing staff. (5) Conduct pre-authorization screening on all affected service lines to identify claims that may now require prior authorization or may be subject to stricter medical necessity review. Failure to obtain required prior authorization or meet new medical necessity criteria will result in claim denials.