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[Ohio] Medical Policies and clinical guidelines updates
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Oct 2, 2026
Summary
Anthem Blue Cross and Blue Shield (Ohio) has updated 12 medical policies and clinical guidelines effective January 1, 2027, including new coverage criteria for gene therapies, cellular immunotherapy, hearing loss treatment, and various diagnostic/surgical procedures. All updated policies require prior authorization. Key changes include reclassification of several procedures from investigational to non-medically necessary status, and transition of multiple policies from Medical Policy to Clinical UM Guideline format.
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What to do
by Dec 31, 2026 · 6 steps
01Billing and clinical staff must review all 12 updated policies at anthem.com (Ohio provider portal > Resources > Medical Policies & Clinical UM Guidelines).
02For each policy marked with *, implement prior authorization requirements in billing system before January 1, 2027.
03Providers must obtain prior authorization for DME.00056 (intrabuccal radiofrequency therapy), MED.00149 (gene therapy for LAD-I), MED.00164 (cellular immunotherapy), MED.00165 (gene therapy for hearing loss), MED.00166 (mucosal integrity testing), CG-MED-107 (autonomic testing), CG-SURG-134 (urinary incontinence treatments), CG-SURG-135 (posterior nasal nerve treatment), CG-MED-102 (dichoptic therapy for amblyopia), CG-SURG-116 (hyperhidrosis surgery), LAB.00046 (Alzheimer biomarkers), and MED.00161 (gene therapy for Wiskott-Aldrich Syndrome) before service delivery.
04Update all encounter forms, clinical decision support tools, and staff training materials to reflect new criteria for medical necessity.
05For guidelines transitioned from Medical Policy to Clinical UM Guideline (CG-MED-107, CG-SURG-134, CG-SURG-135), note that coverage determinations now managed by Carelon Medical Benefits Management.
06Call prior authorization line on member ID card or use Anthem provider portal for authorization requests.
If missed: Failure to obtain required prior authorization will result in claim denials.
Original notice
[Ohio] Medical Policies and clinical guidelines updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Ohio] National accounts: 2027 standard prior authorization requirementsHighEffective Jan 1, 2027 · Provider Bulletin[New York] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Nov 1, 2026 · Prior Authorization[Ohio] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Jan 1, 2027 · Prior Authorization[Ohio] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Nov 28, 2026 · Prior AuthorizationBrowse every Anthem BCBS change in the policy list