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11.02.27o, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)
Act
by Sep 19, 2026
Effective date
Sep 19, 2026
Identified
Sep 22, 2026
Summary
Independence Blue Cross has delegated utilization management for percutaneous coronary intervention, coronary angiography, and arterial ultrasound to Carelon Medical Benefits Management, effective 09/19/2026. All determinations of medical necessity for these procedures will now follow Carelon's Clinical Appropriateness Guidelines instead of Independence's own criteria. Emergency procedures are exempt from utilization management requirements.
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What to do
by Sep 19, 2026 · 7 steps
01Billing and authorization team must implement the following changes.
02Update billing system routing rules to direct all percutaneous coronary intervention (PCI), diagnostic coronary angiography, and arterial ultrasound authorization requests to Carelon Medical Benefits Management instead of Independence's internal review process.
03Obtain and integrate Carelon's current Clinical Appropriateness Guidelines from https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiovascular-guidelines/ into provider education materials and pre-authorization workflows.
04Update authorization templates and clinical decision support tools to reference Carelon guidelines for medical necessity determination.
05Train authorization staff that emergency PCI procedures bypass the utilization management program and do not require prior authorization.
06Verify member eligibility for Carelon program applicability before initiating utilization review, as this policy only applies to members for whom Carelon program is applicable.
07Communicate to cardiology and interventional radiology providers that authorization decisions will now be based on Carelon guidelines effective immediately.
If missed: Failure to route cases to Carelon may result in delayed authorizations, claim denials, and payment disputes.
Original notice
11.02.27o, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)
medpolicy.ibx.com · Always check the source before changing claims.
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