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MA11.113o, Percutaneous Coronary Intervention, Coronary Angiography, and Arterial Ultrasound
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 services to Carelon Medical Benefits Management, effective 09/19/2026. The policy establishes a three-tier medical necessity determination process: first using Medicare NCDs/LCDs, then Carelon's Clinical Appropriateness Guidelines if no Medicare guidance exists, and denying services not addressed in either framework. Emergency procedures are excluded from utilization management.
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What to do
Action · 6 steps
01Billing team must establish processes to route all percutaneous coronary intervention (PCI), diagnostic coronary angiography, and arterial ultrasound claims through Carelon Medical Benefits Management for prior authorization and medical necessity review, except emergent procedures.
02Update billing system to identify these procedure types and automatically flag for Carelon submission.
03Providers must document which Medicare coverage determination (NCD/LCD) or Carelon Clinical Appropriateness Guideline criterion supports medical necessity for each claim.
04Obtain specific procedure codes from Attachment A of policy MA11.113o and configure system to require Carelon pre-authorization before scheduling/billing.
05Train clinical and billing staff that emergency PCI procedures bypass Carelon review.
06Access Carelon's complete Clinical Appropriateness Guidelines at https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiovascular-guidelines/ and incorporate criteria into clinical documentation templates.
If missed: Failure to obtain Carelon authorization will result in claim denials for non-emergency cases.
Original notice
MA11.113o, Percutaneous Coronary Intervention, Coronary Angiography, and Arterial Ultrasound
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
See all Independence Blue Cross changes →11.02.27o, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)HighEffective Sep 19, 2026 · Medical PolicyMA11.113l, Percutaneous Coronary Intervention, Coronary Angiography, and Arterial UltrasoundMediumEffective Nov 15, 2025 · Medical Policy11.02.27l, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)HighEffective Nov 15, 2025 · Medical PolicyBrowse every Independence Blue Cross change in the policy list