MedicaidPrior AuthHigh impact
[New York] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·NY · Cardiology, Cardiothoracic Surgery, Dermatology +9 more·Prior Authorization
Effective date
Oct 18, 2026
We identified it
Sep 17, 2026
Summary
Anthem New York Medicaid has revised multiple medical policies and clinical utilization management guidelines effective October 18, 2026. Changes affect prior authorization requirements, coverage criteria, and medical necessity determinations for 24 policies spanning wound healing products, cardiac procedures, diabetes management devices, lab testing, orthopedic braces, and transplant services. Some previously covered services may now be found not medically necessary under revised criteria.
Action Required
By October 18, 2026: (1) Billing team and clinical staff must review all 24 revised/new policies on Anthem's website at the provided URL. (2) Update billing system logic and prior authorization workflows for affected services including continuous glucose monitoring (CG-DME-42), automated insulin delivery (CG-DME-50), cardiac monitors (CG-MED-40), venous angioplasty/stenting (CG-SURG-106), tibial nerve stimulation (CG-SURG-126), wound healing products (CG-SURG-127), Mohs surgery (CG-SURG-90), and left atrial appendage closure (CG-SURG-133). (3) For lab testing policies (CG-LAB-21, CG-LAB-37, CG-LAB-38), verify billing system requirements for serum iron, PT, and lipid panel testing. (4) Provider education: Distribute the full policy notice to all clinical staff, providers, and office staff before October 18, 2026. (5) Prior Authorization: Confirm which revised policies require new or modified prior auth submission templates in billing software. (6) Claims review: Flag any claims submitted October 18, 2026 forward under old policy criteria for potential denials if they no longer meet new medical necessity standards. Failure to update workflows will result in unexpected claim denials and rework.