What insurance policy changes affect Virginia providers?

This page tracks changes from major payers (including Medicaid managed care, commercial insurers, and Medicare Advantage plans) that explicitly apply to Virginia. Changes include prior authorization updates, billing code additions or deletions, and reimbursement rate revisions.

How often are Virginia policy changes updated?

Our scrapers run daily and publish new findings within 24 hours of detection. Each change includes an effective date where stated so you can prioritize what requires immediate action.

How do I get alerted to new Virginia insurance policy changes?

Create a free alert on PolicyChanges.app and filter by state to Virginia. You will get an email when new matching changes are detected: daily or weekly, your choice, on every plan.

PAYER POLICY CHANGES

Virginia Insurance & Medicaid Policy Updates

Virginia providers face a continuous stream of payer policy changes: coverage edits, prior authorization expansions, billing code revisions, and Medicaid reimbursement updates that affect day-to-day practice operations. This page surfaces every tracked policy change that explicitly names Virginia, so your billing and compliance teams can act before the effective date, not after a claim denial.

Anthem BCBS · Effective Nov 15, 2026High impact
[Virginia] Carelon Medical Benefits Management Clinical Appropriateness Guidelines updates
Carelon Medical Benefits Management updated its clinical appropriateness guidelines for Anthem Medicare Advantage plans in Virginia, effective for dates of service on and after November 15, 2026. Genetic testing changes require that all components of a test demonstrate clinical utility, add imlunestrant to the therapies for which ESR1 mutation testing is considered medically necessary, and state that testing for breast cancer recurrence is not medically necessary. Orthopedic changes standardize conservative management to 12 weeks across procedures, with an allowance for shorter duration for severe ADL impacts, and exclude Kellgren-Lawrence grade 4 osteoarthritis from shoulder, hip and knee arthroscopy.
Anthem BCBS · Effective Nov 20, 2026High impact
[Virginia] Clinical Criteria updates
HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid) is revising 24 clinical criteria for medical drug benefits, affecting coverage requirements for oncology drugs, immunology agents, ophthalmology implants, and specialty pharmaceuticals. Twenty-two existing criteria are being revised (including Opdivo, Yervoy, Tecentriq, and others) and four new criteria are being added (Hepcludex, Decnupaz, Lumvoa, Trutakna). All changes take effect November 20, 2026.
Anthem BCBS · Effective Nov 29, 2026High impact
[Virginia] Clinical Criteria updates
Anthem Blue Cross and Blue Shield has revised 60 clinical criteria policies for medical drug benefits effective November 29, 2026. These revisions affect medical necessity requirements for specialty pharmaceuticals across multiple therapeutic categories including oncology agents, biologics, growth hormones, and rare disease treatments. Billing and clinical teams must review updated criteria in the Clinical Criteria page and coordinate with authorization requirements communicated separately.
Anthem BCBS · Effective Nov 30, 2026High impact
[New York] Update: Unpaid Medicare cost share will be reported with CARC 303
Anthem will report unpaid Medicare cost share for New York and Virginia FIDE (Fully Integrated Dual Eligible) Medicare Advantage patients using CARC 303 with Group Code CO on remittance advice when Medicaid payment is less than Medicare payment. Billing teams must verify QMB eligibility, never bill patients for amounts marked with CARC 303, and issue refunds if patients already paid these protected amounts.
Anthem BCBS · Effective Nov 30, 2026High impact
[Virginia] Update: Unpaid Medicare cost share will be reported with CARC 303
Anthem Blue Cross and Blue Shield will report unpaid Medicare cost shares (deductibles, coinsurance, copayments) using Claim Adjustment Reason Code (CARC) 303 with Group Code CO on remittance advice for New York and Virginia FIDE (Fully Integrated Dual Eligible) plans. Providers must verify QMB eligibility, not bill or collect these amounts from patients, and refund any incorrect patient payments to comply with balance-billing protections.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] Review Excludes1 coding before submitting claims
Beginning December 1, 2026, Anthem Blue Cross and Blue Shield (Virginia) will apply ICD-10-CM Excludes1 Notes editing to inpatient and outpatient medical and behavioral health claims. Billing teams must review diagnosis coding for Excludes1 conflicts before claim submission to prevent denials and resubmission delays. Claims submitted with unresolved Excludes1 conflicts will be ineligible for reimbursement as submitted.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] Review Excludes1 coding before submitting claims
Effective December 1, 2026, HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid) will enforce ICD-10-CM Excludes1 coding edits on all inpatient and outpatient claims. Billing teams must review diagnosis codes for mutually exclusive combinations before submission, or claims will be denied for reimbursement. This is a coding requirement change affecting claim eligibility.
Aetna Better Health of Virginia · Effective Dec 1, 2026High impact
Provider Notification - New Policy Updates - Clinical Payment, Coding, and Policy Changes Effective December 1, 2026
Effective December 1, 2026, Aetna Better Health of Virginia is implementing new age-based eligibility requirements for specific CPT and HCPCS codes under VA Medicaid. Claims will be automatically denied if the member's age falls outside the specified ranges for ESRD dialysis codes (CPT 90957-90970), preventative care codes (CPT 99386-99397), and injectable medications (HCPCS J1307, J3387, J3391). Billing teams must verify member age before claim submission to avoid denials.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
HealthKeepers, Inc. (Anthem) is implementing a new combined reimbursement policy (G-20001) effective December 1, 2026, that prohibits reimbursement for professional and outpatient facility claims billed with modifier 90 (pass-through laboratory billing). Providers must bill laboratory services directly to receive reimbursement at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and eligible for reimbursement. The previous modifier 91 policy (G-06020) will be retired.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization requirements for 5 specialty pharmacy drugs effective December 1, 2026, adding quantity limits for 3 of those drugs, and revising clinical criteria for 11 existing specialty medications. Patients currently receiving these medications without prior authorization will require prior auth requests going forward. Inclusion of NDC codes on claims will expedite processing for drugs billed with NOC codes.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) effective December 1, 2026, that prohibits pass-through laboratory billing with modifier 90 on professional and outpatient facility claims—these claims will no longer be reimbursed. Providers performing lab tests must bill directly. Modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and eligible for reimbursement. The previous modifier 91 policy (G-06020) will be retired.
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Effective December 1, 2026, Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for laboratory services billed with modifier 90 (pass-through billing). Providers must bill directly for laboratory services and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and is consolidated into this new policy. The prior modifier 91 policy (G-06020) is being retired.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] Precertification/prior authorization requirement changes (September 2026 Newsletter)
Anthem Blue Cross and Blue Shield Virginia has issued multiple precertification/prior authorization requirement changes effective on staggered dates (December 1, 2026 and January 1, 2027). The specific policy details are not provided in this newsletter summary, requiring providers to access the full policy text via the referenced link to determine which services are affected and what documentation is required.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] Precertification/prior authorization requirement changes
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage (ISNP and CSNP plans) in Virginia will require prior authorization for 30 new procedure and supply codes, including prostate cancer screening, skin grafting procedures, esophageal procedures, neurolytic injections, wound care products, and durable medical equipment. Claims submitted without prior authorization for these codes will be denied as ineligible for payment.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Payment discontinued for select procedure codes effective
Effective January 1, 2027, HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid in Virginia) will discontinue reimbursement for 44 specific procedure codes to align with the Virginia Department of Medical Assistance Services (DMAS) fee schedule. The practice must stop billing these codes for dates of service on or after that date, as claims for discontinued codes will be denied or subject to adjustment and recovery.
Sentara Health Plans · Effective Jan 1, 2027High impact
Clinical Policy Updates - Effective January 1, 2026
Effective January 1, 2027, Sentara Health Plans will require prior authorization and/or step therapy precertification for 17 injectable oncology and hematology codes (filgrastim, sargramostim, bevacizumab, pegfilgrastim, rituximab, and trastuzumab products and biosimilars) for Medicare Advantage members in Virginia. The billing team must obtain prior authorization before claims are submitted to avoid denial.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] National accounts: 2027 standard prior authorization requirements
Anthem Blue Cross and Blue Shield's October 2026 notice lists the services that will require prior authorization for national accounts commercial members starting January 1, 2027. The list is broad, covering inpatient admissions (including OB stays beyond the federal minimum length of stay), genetic and diagnostic tests, durable medical equipment, transplant and cell and gene therapies, behavioral health programs, cosmetic and reconstructive surgery, and implanted devices, so scheduling and billing need updates before that date.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Specialty pharmacy precertification list expands
Anthem Blue Cross and Blue Shield (Virginia) is expanding its specialty pharmacy precertification requirements for Medicare Advantage members. Effective January 1, 2027, step therapy precertification will apply to multiple Part B medications (denosumab, bendamustine, pemetrexed, and hyaluronate products). Additionally, effective February 1, 2027, three new specialty drugs (golimumab-sldi, bevacizumab-vikg, and isatuximab-irfc) will require precertification review. Noncompliance with these new requirements may result in claim denial.
Sentara Health Plans · Effective Jan 1, 2027High impact
Authorization Updates - Effective January 1, 2027
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] National accounts: 2027 standard prior authorization requirements
Anthem Blue Cross and Blue Shield (Virginia) is expanding its prior authorization (PA) requirements effective January 1, 2027, for national accounts. The policy now mandates pre-certification for numerous advanced procedures, diagnostic tests, durable medical equipment, gene therapies, CAR T-cell treatments, transplants, mental health services, and surgical procedures. This represents a comprehensive broadening of PA scope across multiple service categories.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (October 2026 Newsletter)
Carelon Medical Benefits Management (serving Anthem Blue Cross and Blue Shield in Virginia) has updated precertification/prior authorization requirements for Base Surgical procedures, effective January 1, 2027, for both Commercial and Medicare Advantage plans. The specific details of which procedures now require prior authorization are not fully disclosed in this newsletter excerpt.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Prior authorization requirement changes (October 2026 Newsletter)
Anthem Blue Cross and Blue Shield (Virginia) and HealthKeepers, Inc. are implementing prior authorization requirement changes effective January 1, 2027. The policy bulletin references updates for Medicare Advantage and Medicaid products, but the specific details of which services require new or modified prior authorization are not included in this summary document. Billing teams must access the detailed policy documents linked in this bulletin to identify affected procedures.
UnitedHealthcare · Effective Jan 1, 2027High impact
New oncology prior authorization code updates
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Specialty pharmacy updates
Effective January 1, 2027, Anthem Blue Cross and Blue Shield in Virginia is implementing new prior authorization requirements for three specialty chemotherapy drugs (Avgemsi, Docivyx, and Beizray) and establishing step therapy protocols for multiple pemetrexed and bendamustine formulations. Patients currently receiving these medications without prior authorization may require it going forward, necessitating updated billing workflows and prior authorization processes.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Precertification/prior authorization requirement changes
Effective January 1, 2027, Anthem Blue Cross and Blue Shield will require prior authorization for 27 new procedure and supply codes for Medicare Advantage members in Virginia, including prostate cancer screening (0591U), skin graft procedures (1044T-1049T), esophageal procedures (43192, 43201, 43210, 43236, 43497), nerve destruction (64624), wound care matrices, neurostimulator devices, and orthotic devices. Claims submitted without prior authorization for these services will be denied.
Anthem BCBS · Effective Feb 1, 2027High impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective for dates of service on or after February 1, 2027, the listed codes will require precertification or prior authorization through Carelon Medical Benefits Management for Anthem Blue Cross and Blue Shield HMO and PPO plans offered in Virginia. The added codes cover full-thickness skin harvest and autologous heterogeneous skin-construct graft application, a long list of skin substitute products, and neurostimulator generators (C1826 and C1827). These services are being added to the review program to support consistent application of current clinical guidelines and evidence-based coverage criteria.
Virginia Medicaid - DMAS · Effective Jun 30, 2027High impact
Behavioral Health Services Redesign Implementation Dates
Virginia Medicaid is redesigning behavioral health services, retiring four Community Mental Health Rehabilitative Services (CMHRS) codes (H2012, H2016, H0046, H2017) effective June 30, 2027, and implementing five new behavioral health service codes (CPST-Adult, CPST-Youth Community, CPST-Youth School, CSC, Clubhouse) effective July 1, 2027. All current members receiving the retiring services must transition to alternative behavioral health services by the deadline. The practice must update provider enrollment, verify credentials, and prepare for service authorization transitions over the next 6-12 months.
Anthem BCBS · Effective Nov 15, 2026Medium impact
[Virginia] Carelon Medical Benefits Management updates
Anthem Blue Cross and Blue Shield in Virginia is adopting Carelon Medical Benefits Management Clinical Appropriateness Guidelines effective November 15, 2026, for two procedures: Cardiovascular Catheter-Based Closure of Patent Foramen Ovale and Surgical Upper Gastrointestinal Endoscopy. Existing prior authorization requirements remain unchanged, but providers should monitor for future prior authorization updates that will be communicated separately.
Anthem BCBS · Effective Nov 15, 2026Medium impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Carelon Medical Benefits Management has added an exclusion for bilateral hypoglossal nerve stimulators in the treatment of obstructive sleep apnea, effective November 15, 2026. Providers must now obtain prior authorization for any hypoglossal nerve stimulator procedures and ensure unilateral (single-sided) implants only for Medicaid coverage under HealthKeepers, Inc. and Anthem HealthKeepers Plus in Virginia.
Anthem BCBS · Effective Nov 15, 2026Medium impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Anthem Blue Cross and Blue Shield in Virginia is updating its Carelon Medical Benefits Management Clinical Appropriateness Guidelines for dates of service on and after November 15, 2026. The updates cover procedures including patent foramen ovale closure, varicose vein treatment, vascular embolization, genetic testing, musculoskeletal joint surgery and upper gastrointestinal endoscopy. Carelon is a separate company that provides utilization review services on behalf of the health plan.
Anthem BCBS · Effective Nov 30, 2026Medium impact
[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
HealthKeepers, Inc. (Anthem) is updating 26 medical policies and clinical utilization management guidelines for Virginia Medicaid members effective November 30, 2026. Changes include new policies for gene therapies, cellular immunotherapy, and cancer treatments, plus revisions to existing guidelines for procedures including breast surgery, deep brain stimulation, and various surgical/rehabilitation services. Some policy changes may result in services previously covered being classified as not medically necessary.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Prior authorization and step therapy updates for medications billed under the medical benefit
HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid) is adding prior authorization requirements for three specialty pharmacy drugs (Immgolis, Immgolis Intri, and Sarclisa Escena) and implementing step therapy reviews for multiple bendamustine and pemetrexed formulations when billed under the medical benefit, effective December 1, 2026. Billing teams must obtain prior authorization for these medications on or after this date and ensure NDC codes are included on medical claims.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Prior authorization required for MED.00164
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in Virginia now requires prior authorization for MED.00164 (Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome). Billing teams must obtain precertification before providing this service to ensure accurate reimbursement and avoid claim denials.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (September 2026 Newsletter)
Carelon Medical Benefits Management has updated prior authorization and precertification requirements for Virginia commercial plans, effective December 1, 2026. Changes span Additional Outpatient and Cardiovascular service categories. The billing team must identify which specific procedures now require prior authorization under these updated guidelines.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Precertification/prior authorization list change notification
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in Virginia is adding compression devices for lymphedema (HCPCS code E0659) to its precertification/prior authorization requirements. Providers must obtain prior authorization before rendering this service or claims may be denied as ineligible for payment.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (including HealthKeepers, Inc.) in Virginia will require prior authorization through Carelon Medical Benefits Management for CPT code 1020T (Raman spectroscopy of skin lesions with malignant risk analysis). This applies to all PPO and HMO commercial plans in Virginia. Billing teams must update authorization workflows to route this procedure through Carelon before service delivery.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] VA precertification/prior authorization list change notification
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in Virginia is adding three services to its precertification/prior authorization requirement list: noninvasive imaging for skin lesion evaluation (CPT 1020T), and two percutaneous spinal surgery procedures (CPT 62330 and 62331). Providers must obtain prior authorization before rendering these services or risk claim denial.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (including HealthKeepers, Inc.) in Virginia now requires precertification/prior authorization for two radiation therapy CPT codes (19294 and 19297) related to intraoperative and interstitial radiotherapy during partial mastectomy procedures. All PPO and HMO commercial plans are affected. Billing teams must implement prior authorization requirements before this date or claims will be denied.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Precertification/prior authorization list change notification
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in Virginia is adding 14 new services to its precertification/prior authorization requirement list. These include four advanced laboratory tests (Alzheimer's biomarkers, IBS serology, infectious disease sequencing, and prostate cancer protein biomarkers), two irreversible electroporation procedures, six carotid sinus baroreceptor stimulation device codes, and two gene therapy treatments. All services require prior authorization before delivery or claims may be denied.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Federal Employee Program Overpayment Recovery and Dispute Process Mandate
Effective January 1, 2027, Anthem Blue Cross and Blue Shield is implementing a new overpayment recovery and dispute process for the Federal Employee Program (FEP) in Virginia. The payer will now recover overpayments through provider offsets after initial written notice, refer outstanding balances to collection after 180 days, and provide a formal dispute process where providers have 30 calendar days to submit written explanations and supporting evidence after receiving a 15-day information request from the payer.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] 2027 Medicare formulary changes: Prepare now for
Beginning January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia will move 10 commonly used medications to nonformulary status, including Anoro Ellipta, Brilinta, Janumet, Januvia, Jentadueto, Opsumit, Spiriva, Stelara, Xeljanz, and Xigduo XR. The practice should review patient medication lists now, use Real-Time Prescription Benefit tools to identify covered alternatives, and work with providers to transition patients to covered options before the effective date to avoid pharmacy claim denials and treatment delays.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] New prior authorization requirements
Effective January 1, 2027, Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. (Medicare Advantage) in Virginia will require prior authorization for eight newly specified procedure and test codes, including oncology assays, diagnostic imaging, ultrasound therapy, and spinal procedures. Billing teams must submit authorization requests through Availity before providing these services to avoid claims processing delays.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Upcoming claims adjustments for 2025 custodial care overpayments
Anthem HealthKeepers Plus will automatically reprocess custodial care claims from January 1–December 31, 2025, to correct overpayments caused by incorrect monthly patient liability deductions. Reprocessing begins January 1, 2027, and overpayments will be recovered through negative claim balances applied to future payments. No action is required from providers unless they disagree with adjustments; disputed cases may be appealed via the explanation of payment.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Precertification list change notification
Anthem Blue Cross and Blue Shield is adding seven new services to its precertification (prior authorization) requirements effective January 1, 2027. These include durable medical equipment, gene therapy, prosthetic devices, and surgical procedures. Billing teams must obtain precertification for these services before rendering them to avoid claim denials and reimbursement complications.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Prior authorization requirement changes
Effective January 1, 2027, HealthKeepers, Inc. requires precertification or prior authorization for the listed codes for Anthem HealthKeepers Plus members. The added codes include 0591U, a prostate cancer prognostic test that analyzes 3 proteins (total PSA, free PSA, and HE4), along with skin substitute products for wound care, two implantable neurostimulator generators (C1826, C1827), and a lower extremity prosthesis foot shell (L5992). If the requirements are not met, those services may be deemed ineligible for payment.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective for dates of service on or after January 1, 2027, the following codes will require precertification or prior authorization through Carelon Medical Benefits Management. These services are being added to the review program to support consistent application of current clinical guidelines and evidence-based coverage criteria. The codes cover autologous heterogeneous skin-construct and skin substitute services, esophagoscopy and esophagogastroduodenoscopy procedures, lower esophageal myotomy (POEM), and implantable neurostimulator generators.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective January 1, 2027, Anthem Blue Cross and Blue Shield in Virginia is adding two codes to its prior authorization requirement list through Carelon Medical Benefits Management: CPT 64595 (neurostimulator pulse generator revision/removal) and HCPCS Q4391 (amnioplast double). This applies to all PPO and HMO commercial plans. Billing teams must obtain precertification before submitting claims for these services to avoid denials.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Prior authorization requirement changes
Effective January 1, 2027, Anthem Blue Cross and Blue Shield and HealthKeepers in Virginia are adding two codes to their prior authorization requirements: CPT 64595 (neurostimulator pulse generator revision/removal) and HCPCS Q4391 (amnioplast double). All services using these codes will require precertification through Carelon Medical Benefits Management before delivery of service.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Precertification/prior authorization list change notification
Effective January 1, 2027, Anthem Blue Cross and Blue Shield (Virginia) is adding two CPT codes for surgical treatment of hyperhidrosis (32664 and 64818) to their precertification/prior authorization requirements. Providers must obtain prior authorization before rendering these services, or claims will be deemed ineligible for payment.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Precertification/prior authorization list change notification
Effective January 1, 2027, Anthem Blue Cross and Blue Shield (Virginia) is adding Dichoptic Digital Therapy for Amblyopia (CPT codes 0687T, 0688T, 0704T, 0705T, 0706T, and HCPCS A9292) to its precertification/prior authorization requirements. Providers must obtain prior authorization before rendering these services or claims may be denied as ineligible for payment.

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[Virginia] Clinical Criteria updates

[Virginia] Clinical Criteria updates

[New York] Update: Unpaid Medicare cost share will be reported with CARC 303

[Virginia] Update: Unpaid Medicare cost share will be reported with CARC 303

[Virginia] Review Excludes1 coding before submitting claims

[Virginia] Review Excludes1 coding before submitting claims

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[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

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[Virginia] Precertification/prior authorization requirement changes

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[Virginia] National accounts: 2027 standard prior authorization requirements

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (October 2026 Newsletter)

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[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

[Virginia] Medical Policies and Clinical Utilization Management Guidelines update

[Virginia] Prior authorization and step therapy updates for medications billed under the medical benefit

[Virginia] Prior authorization required for MED.00164

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (September 2026 Newsletter)

[Virginia] Precertification/prior authorization list change notification

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Virginia] VA precertification/prior authorization list change notification

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Virginia] Precertification/prior authorization list change notification

[Virginia] Federal Employee Program Overpayment Recovery and Dispute Process Mandate

[Virginia] 2027 Medicare formulary changes: Prepare now for

[Virginia] New prior authorization requirements

[Virginia] Upcoming claims adjustments for 2025 custodial care overpayments

[Virginia] Precertification list change notification

[Virginia] Prior authorization requirement changes

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Virginia] Prior authorization requirement changes

[Virginia] Precertification/prior authorization list change notification

[Virginia] Precertification/prior authorization list change notification