Medicare AdvantagePrior AuthHigh impact
[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·VA · Cardiology, Cardiothoracic Surgery, Vascular Surgery +9 more·Prior Authorization
Effective date
Sep 28, 2026
We identified it
Aug 27, 2026
Summary
Anthem Blue Cross and Blue Shield (Virginia) is updating 24 Medical Policies and Clinical Utilization Management Guidelines effective September 28, 2026. This includes revised coverage criteria for high-impact procedures (cardiac valve replacements, wound healing products, glucose monitoring, insulin delivery systems) and new guidelines for laboratory testing and specialized therapies. Some previously covered services may now be classified as not medically necessary under the updated criteria.
Action Required
By September 28, 2026: Billing and clinical teams must review all 24 updated policies on Anthem's Medical Policies and Clinical UM Guidelines website (reference document does not provide specific CPT/HCPCS codes but lists policy numbers: SURG.00011, SURG.00032, SURG.00121, TRANS.00008, CG-DME-42, CG-DME-44, CG-DME-50, CG-LAB-21, CG-LAB-37, CG-LAB-38, CG-MED-101, CG-MED-40, CG-MED-68, CG-OR-PR-02, CG-SURG-106, CG-SURG-126, CG-SURG-127, CG-SURG-131, CG-SURG-132, CG-SURG-133, CG-SURG-90, CG-TRANS-04). For each affected specialty area in your practice, obtain the full policy detail and: (1) Update billing software to implement new prior authorization requirements; (2) Modify encounter forms and templates to reflect changed medical necessity criteria; (3) Provide provider education on expanded rationales and new authorization thresholds; (4) Update charge capture rules for services that may shift from covered to investigational or non-covered status. Failure to implement these changes will result in claim denials and potential compliance violations. This is a multi-department effort requiring coordination between billing, clinical documentation, and provider relations teams.