Medicare AdvantagePrior AuthHigh impact
[New York] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·NY · 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 has updated 24 medical policies and clinical utilization management guidelines effective September 28, 2026, affecting prior authorization requirements, coverage criteria, and medical necessity determinations across multiple service categories including cardiac procedures, diabetes management devices, laboratory testing, wound care, and surgical interventions. Some previously covered services may now be found not medically necessary under revised criteria.
Action Required
By September 28, 2026: Billing team and clinical staff must obtain and review the full text of all 24 revised/new policies from Anthem's Medical Policies and Clinical UM Guidelines website (referenced in policy document). For each revised policy affecting your practice specialties, identify corresponding CPT/HCPCS codes and update: (1) Prior authorization workflows in billing system; (2) Encounter templates and order entry to reflect new medical necessity criteria; (3) Staff training on documentation requirements for affected services. Critical policy areas requiring immediate attention: CG-DME-42 (Continuous Glucose Monitoring), CG-DME-50 (Automated Insulin Delivery), CG-MED-40 (External Ambulatory Cardiac Monitors), CG-SURG-131 (Transcatheter Aortic Valve), CG-SURG-133 (Left Atrial Appendage Closure), and wound healing products (SURG.00011/CG-SURG-127). Claims submitted without compliance to revised criteria will be denied as not medically necessary. Designate a compliance staff member to download detailed guidelines from Anthem provider portal and map to your practice's common billing codes before the effective date.