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[California] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Effective date
Apr 4, 2026
Identified
May 3, 2026
Summary
Carelon Medical Benefits Management has updated its Clinical Appropriateness Guidelines effective April 4, 2026, with extensive revisions across radiology, oncologic imaging, radiation oncology, genetic testing, and rehabilitation services. Changes include alignment with ACR and NCCN standards, removal of certain imaging requirements, expanded indications for cancer treatments and genetic testing, and addition of new genetic testing sections. Billing teams must review specialty-specific changes to ensure proper prior authorization and claim processing for affected services.
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What to do
Action · 7 steps
01Before April 4, 2026: 1) Billing and clinical teams must review the full Carelon Medical Benefits Management Clinical Appropriateness Guidelines at the provider portal (providerportal.com) and identify all changes applicable to your practice specialties.
022) Update prior authorization protocols in your billing system for radiology imaging changes (abdomen/pelvis, chest, head/neck imaging), oncologic imaging (breast, lung, pancreatic, colorectal, and other cancers), radiation oncology treatments (SBRT, APBI, SIRT), and expanded genetic testing indications.
033) Implement new genetic testing codes 81218, 81310, 81334, 81338, 81339, and 81345 into billing workflows and ensure providers understand expanded hereditary cancer testing criteria.
044) Remove prior authorization requirements for previously restricted services that are now simplified or removed (e.g., sports hernia imaging, certain SBO pediatric imaging).
055) Notify providers of expanded clinical scenarios for radiation therapy and PSMA PET imaging.
066) For oncology and genetics providers, document new indications for genetic testing (Hereditary Diffuse Gastric Cancer, Hereditary Myeloid Neoplasms, Hereditary Brain Tumors, expanded kidney cancer gene lists).
077) Contact Carelon at MedicalBenefitsManagement.guidelines@Carelon.com if clarification is needed on specific changes.
If missed: Failure to update prior authorization criteria may result in claim denials or payment delays.
Codes mentioned
812188131081334813388133981345
Original notice
[California] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
providernews.anthem.com · Always check the source before changing claims.
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