Policy Updates Prior AuthorizationMedicare AdvantageOctober 19, 2023

Expansion of Carelon Medical Benefits Management, Inc. programs

Effective April 1, 2024, Carelon Medical Benefits Management, Inc. will expand multiple programs to perform medical necessity reviews for additional procedures for Anthem Blue Cross and Blue Shield members. Carelon Medical Benefits Management works to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping to promote care that is appropriate, safe, and affordable.

The expansion will require clinical appropriateness review for additional procedures related to the Carelon Medical Benefits Management cardiology, genetic testing, radiology, musculoskeletal, surgical and radiation therapy programs.

Carelon Medical Benefits Management will follow the clinical hierarchy established by Anthem Blue Cross and Blue Shield for medical necessity determination. Anthem Blue Cross and Blue Shield makes coverage determinations based on CMS guidance, including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, Carelon Medical Benefits Management will determine medical necessity using an objective, evidence-based process.

Carelon Medical Benefits Management will continue to use criteria documented in Anthem Blue Cross and Blue Shield’s Medical Policies and Clinical Guidelines listed in the table below. These Clinical Guidelines can be found at Availity.com.

Detailed prior authorization (PA) requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at Availity.com. Contracted and noncontracted care providers should call Provider Services at the phone number on the back of the member’s ID card for PA requirements.

Prior authorization review requirements

Carelon Medical Benefits Management will begin accepting PA requests on March 18, 2024, for dates of service April 1, 2024 and after. For procedures scheduled to begin on or after April 1, 2024, care providers must contact Carelon Medical Benefits Management to obtain PA for the below non-emergency modalities. Refer to the Clinical Guidelines on the microsite resource pages for complete code lists.

Program

Services

Medical Policies or Clinical Guidelines

Cardiology

•Cardiac monitor device

•Cardiac contractility modulation

CG-MED-74

SURG.00153

Genetic testing

•Chromosomal microarray analysis

•Gene expression profiling

•Gene mutation testing

•Gene sequencing

•DNA-based prenatal testing

•Panel and other multi-gene testing for polymorphisms

•Genetic testing for inherited diseases

•Molecular marker evaluation of thyroid nodules

•Hybrid personalized molecular residual disease testing for cancer

CG-GENE-04

CG-GENE-10

CG-GENE-13

CG-GENE-14

CG-GENE-21

CG-GENE-22

GENE.00010

GENE.00023

GENE.00052

GENE.00053

GENE.00056

GENE.00057

GENE.00059

TRANS.00025

Radiology

•Radiostereormetric analysis

•Breast MRI

Breast MRI guideline

RAD.00065

Musculoskeletal

•Percutaneous and endo spinal surgery

•Open SI joint fusion

•Ultrasound bone growth stimulation

•Cryoablation for podiatric conditions

•Nerve stimulation devices for pain

SURG.00071

SURG.00100

SURG.00147

SURG.00158

Surgical

•Tx of GE reflux, dysphagia, gastroparesis

SURG.00047

Radiation therapy

•Hyperthermia for cancer therapy

CG-MED-72


To determine if PA is needed for a member on or after April 1, 2024, call Provider Services using the phone number on the back of the member’s ID card. Care providers using the interactive care reviewer (ICR) tool on Availity.com for PA requests on an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept PA requests for services administered by Carelon Medical Benefits Management.)

How to place a review request

Care providers may place a PA request online to Carelon Medical Benefits Management via providerportal.com. ProviderPortalSM is available 24/7, processing requests in real-time using clinical criteria.

For more information

For resources to help your practice get started with the radiology, cardiology, genetic testing, musculoskeletal, surgical, and radiation oncology programs, visit:

Our website helps you access information and tools such as order entry checklists, Clinical Guidelines, and FAQs.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. Availity Essentials is an independent company providing prior authorization and billing services on behalf of the health plan.

MULTI-BCBS-CR-038666-23-CPN38554

PUBLICATIONS: November 2023 Provider Newsletter