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[New York] Medical Policy and Clinical Guideline updates
Effective date
Feb 1, 2027
Identified
Nov 3, 2026
Summary
Anthem is issuing new and revised medical policies and clinical guidelines effective February 1, 2027, for multiple services including ocular pressure devices, oxygen therapy, prosthetics, cardiac monitoring, cosmetic surgery, biomarker tests, orthoses, sleep apnea surgery, autonomic testing, and infusion pumps. Services previously covered may now be found not medically necessary or investigational, and claims submitted on or after the effective date will be subject to these updated policies.
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What to do
Action · 7 steps
01Before February 1, 2027.
02Billing team and providers should review the complete medical policies and clinical guidelines for the affected services listed at anthem.com/provider under Medical Policies & Clinical UM Guidelines for New York Commercial plans.
03For each affected service the practice currently bills (ocular pressure adjusting pumps, topical continuous diffusion oxygen therapy, external lower extremity sensory prosthetics, implantable heart failure remote monitoring devices, cosmetic/reconstructive trunk/groin/extremity services, blood-based MS biomarkers, non-invasive cardiac monitoring systems, upper extremity myoelectric orthoses, oral/pharyngeal/maxillofacial sleep apnea surgery, autonomic testing, and implantable infusion pumps), determine which now require prior authorization or have changed medical necessity criteria.
04Update charge entry and claim edits in your system to ensure claims for these services go out with current prior authorization status and required clinical documentation before February 1, 2027.
05Tell providers and front desk staff which services now require prior authorization or have tighter coverage rules, and provide guidance on required clinical documentation.
06For claims submitted on or after February 1, 2027 without updated authorization or documentation, expect denial on medical necessity or investigational grounds.
07Note: This applies only to Anthem Commercial plans in New York; FEP Blue members are governed by separate policies at fepblue.org.
Original notice
[New York] Medical Policy and Clinical Guideline updates
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[New York] Medical Policy and Clinical Guideline updatesMediumEffective Jan 1, 2027 · Medical Policy[New York] Medical Policy and Clinical Guideline updatesHighEffective May 1, 2026 · Medical PolicyBrowse every Anthem BCBS change in the policy list