Medical Policies and Clinical Utilization Management Guidelines Update (February 2023)

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. 

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit anthem.com/provider/policies/clinical-guidelines/search/.

Medical Policies

On February 16, 2023, the Medical , and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Anthem Blue Cross and Blue Shield Medicaid (Anthem). These guidelines take effect August 27, 2023.

Carelon Medical Benefits Management, Inc.* updates:

Effective for dates of service on and after September 10, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for medical necessity review for Anthem: 

• Musculoskeletal guidelines:
  • Spine surgery
  • Sacroiliac joint fusion
• Sleep disorder management guideline:

Effective for dates of service on and after August 1, 2023, MRI of the Breast – RAD.00036 is transitioning to Carelon Medical Benefits Management criteria in the following two guidelines:

• Imaging of the chest
• Oncologic imaging