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[New York] Medical Policies and Clinical Utilization Management Guidelines update
Act
by Oct 31, 2026
Effective date
Nov 1, 2026
Identified
Sep 29, 2026
Summary
Anthem Blue Cross and Blue Shield has updated 27 medical policies and clinical utilization management guidelines effective November 1, 2026. These changes include new coverage policies for gene therapies, cellular immunotherapy, and emerging treatments, plus revisions to existing policies for common procedures like breast surgery, deep brain stimulation, cardiac rehabilitation, and cochlear implants. Some policy changes may result in previously covered services being determined as not medically necessary.
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What to do
by Oct 31, 2026 · 13 steps
01Billing and clinical teams must review all 27 updated medical policies and clinical UM guidelines on the Anthem Medical Policies & Clinical UM Guidelines website.
02Identify which policies apply to your practice's specialties and procedures.
03Update prior authorization workflows, billing system rules, and clinical documentation templates to align with new medical necessity criteria.
04Review the following policy categories for your practice.
05Gene therapy policies (MED.00135, MED.00140, MED.00149, MED.00161, MED.00165).
06Cellular immunotherapy (MED.00164).
07Surgical procedures (SURG.00023 breast, SURG.00026 neuromodulation, CGSURG-24 FESS, CG-SURG-51 cystourethroscopy, CG-SURG-81 cochlear implants, CG-SURG-134 urinary incontinence, CG-SURG-135 rhinitis treatment).
08Rehabilitation services (CG-REHAB-02 cardiac, CG-REHAB-03 pulmonary).
09Diagnostic testing (LAB.00046 Alzheimer markers, CG-LAB-38 lipid panels, CG-RAD-33 spinal visualization).
10Medical management (CG-DME-44 TTF therapy, CG-MED-69 inhaled nitric oxide, CG-MED-99 intradialytic nutrition, CG-MED-107 autonomic testing, CG-TRANS-02 kidney transplant).
11Train providers and billing staff on new coverage criteria.
12Monitor for claim denials related to medical necessity determinations on services previously covered.
13Establish internal process to track policy compliance for Medicare Advantage patients.
Original notice
[New York] Medical Policies and Clinical Utilization Management Guidelines update
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[New York] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Nov 30, 2026 · Prior Authorization[Ohio] Medical Policies and clinical guidelines updatesHighEffective Jan 1, 2027 · Provider Bulletin[New York] Medical Policies and Clinical Utilization Management Guidelines update (October 2026 Newsletter)MediumNo effective date · Prior Authorization[California] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Nov 1, 2026 · Prior AuthorizationBrowse every Anthem BCBS change in the policy list