CommercialCoverageHigh impact
[New York] Clinical Criteria updates for specialty pharmacy
Anthem BCBS·NY · Oncology, General Surgery, Vascular Surgery +3 more·Pharmacy
Effective date
Aug 1, 2026
We identified it
May 3, 2026
Summary
Anthem has revised multiple medical policies and clinical guidelines effective August 1, 2026, affecting coverage for prostate cancer biomarker screening, wound healing products, renal denervation, cryosurgery, venous angioplasty, vagus nerve stimulation, tibial nerve stimulation, and related procedures. Services previously covered may now be denied as not medically necessary or investigational. Billing teams must review affected policies to prevent claim denials on or after the effective date.
Action Required
By July 15, 2026: Billing and clinical teams must review the complete revised medical policies and clinical guidelines on Anthem's provider portal (anthem.com/provider > Medical Policies & Clinical UM Guidelines). Specifically review: LAB.00033 (Prostate Cancer Biomarkers), SURG.00011 (Wound Healing Products), SURG.00135 (Renal Denervation), SURG.00155 (Cryosurgery), CG-SURG-106 (Venous Angioplasty/Stenting), CG-SURG-120 (Vagus Nerve Stimulation), CG-SURG-126 (Tibial Nerve Stimulation), and CG-SURG-127 (Wound Healing Products). Update internal documentation of coverage criteria. Communicate changes to providers to ensure proper documentation of medical necessity for claims submitted on or after August 1, 2026. Failure to comply will result in claim denials for services that no longer meet medical necessity criteria. No reprocessing of pre-August 1 claims will occur.