Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Effective for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Radiation Oncology:

• IMRT for Colon Cancer
• New indication for adjuvant treatment of locally advanced adenocarcinoma of the cecum.
• SBRT for Hepatocellular Carcinoma
• Modify eligibility criteria to match clinical trial RTOG 1112
• EBRT/IMRT for Prostate Cancer
• Adjust for 2 Gy fractions. The total allowed dosage is the same with each fraction is a little larger (now 2 Gy) and lower number of fractions.

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following:

• Access Carelon Medical Benefits Management’s provider portal directly at providerportal.com:
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to guidelines, contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.