CommercialFebruary 4, 2025
Expansion of Carelon Medical Benefits Management, Inc. programs
- Effective March 1, 2025, Carelon Medical Benefits Management will begin conducting clinical appropriateness reviews of cardiovascular, musculoskeletal, and surgical procedures.
- New outpatient utilization management also includes fertility procedures and other medical services for select insurance plans.
- Anthem will continue to perform reviews of transportation services.
- Providers are encouraged to use an online portal for service preauthorization, with resources and training available for guidance.
Carelon Medical Benefits Management will begin accepting prior authorization requests on February 24, 2025, for dates of service on or after March 1, 2025.
Members included in the new program
Updates to Carelon Medical Benefits Management programs apply to select local fully insured members and members covered under self‑insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare supplemental, or Federal Employee Program® (FEP®) plans. For more information, please call the phone number on the back of the member ID card.
Pre‑service review requirements
For procedures scheduled to begin on or after March 1, 2025, all care providers need to contact Carelon Medical Benefits Management to obtain a pre‑service review for the services, including, but not limited to, the following non‑emergency modalities. Please refer to the Clinical Guidelines at Anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.
Note: All codes will be reviewed for medical necessity for the requested service and not for site of care.
The tables below list our Clinical UM Guidelines and Medical Policies for medical necessity review.
|
Program — Additional outpatient UM | |
|
Services |
Medical Policies or Clinical Guidelines |
|
Fertility |
CG-MED-68 |
|
Therapeutic Apharesis |
MED.00101 |
|
Hyperbaric Oxygen Therapy |
CG-MED-89 |
|
Physiologic Record of Tremor |
CG-MED-73 |
|
Parenteral Nutrition |
DME.00011 |
|
Imaging Eval. of Skin Lesions |
DME.00048 |
|
Virtual Reality-Assisted Therapy Systems |
MED.00011 |
|
Quantitative Sensory Test |
MED.00082 |
|
Automated Nerve Conduction |
MED.00092 |
|
Bioimpedance Spectroscopy |
MED.00103 |
|
Autonomic Test |
MED.00105 |
|
Monitor Intraocular Pressure |
MED.00112 |
|
Seizure Monitoring |
MED.00118 |
|
Home Visual Field Monitor |
MED.00130 |
|
Eye Movement Analysis for Dx of Concussion |
MED.00131 |
|
Colonic Irrigation |
MED.00137 |
|
Electrical Stim. Tx. for Pain & Other Conditions |
MED.00141 |
|
Sensory Stim. for Brain Injury |
MED.00002 |
|
Automated Evacuation of Meibomian Gland |
MED.00004 |
|
Selected Sleep Testing |
CG-MED-66 |
|
|
CG-MED-88 |
|
|
CG-SURG-35 |
|
|
LAB.00045 |
|
Program — Cardiovascular | |
|
Services |
Medical Policies or Clinical Guidelines |
|
Carotid Sinus Baroreceptor Stim. Devices |
CG-SURG-106 |
|
Venous angioplasty w/wo stent placement |
CG-SURG-119 |
|
Vein embolization tx for pelvic congestion syndrome and varicocele |
CG-SURG-28 |
|
Tx of varicose veins |
CG-SURG-76 |
|
Artery stent placement w/wo angioplasty |
CG-SURG-83 |
|
Embolization proc. Dialysis circuit proc. |
CG-SURG-93 |
|
|
RAD.00059 |
|
|
SURG.00062 |
|
|
SURG.00124 |
|
Program — Musculoskeletal | |
|
Services |
Medical Policies or Clinical Guidelines |
|
Peripheral Nerve Blocks for Tx of Neuropathic Pain Implant of Nerve Stim. Devices |
SURG.00140 |
|
|
SURG.00158 |
|
|
SURG.00112 |
|
Program — Surgical | |
|
Services |
Medical Policies or Clinical Guidelines |
|
Anesthesia for Dental Svcs. |
SURG.00045 |
|
Skin Related Cosmetic & Reconstructive Services |
SURG.00112 |
|
Balloon Dilation of Eustachian Tubes |
SURG.00144 |
|
Functional Endoscopic Sinus Surgery |
SURG.00129 |
|
Bronchial Thermoplasty |
ANC.00007 |
|
Balloon Sinus Ostial Dilation |
CG-MED-41 |
|
Cochlear & Auditory Brainstem Implants |
CG-MED-79 |
|
Implantable Hearing Aids |
CG-MED-81 |
|
Surg. Tx for OSA & Snoring |
CG-SURG-03 |
|
Drug-Eluting Devices to Maintain Sinus Ostial Patency |
CG-SURG-08 |
|
Minimally Invasive Tx of Posterior Nasal Nerve for Rhinitis |
CG-SURG-09 |
|
Temporomandibular Disorders |
CG-SURG-105 |
|
Septoplasty |
CG-SURG-117 |
|
Nasal Valve Repair |
CG-SURG-118 |
|
Bariatric Surgery |
CG-SURG-12 |
|
MRI Guided US Ablation for Non-Oncologic Indications |
CG-SURG-120 |
|
Uterine Fibroid Ablation |
CG-SURG-18 |
|
Sacral Nerve Stim. Tx of Neurogenic Bladder secondary to Spinal Cord Injury |
CG-SURG-24 |
|
Vagus Nerve Stim. |
CG-SURG-61 |
|
Ablation for Solid Tumors Outside the Liver |
CG-SURG-71 |
|
Irreversible Electroporation |
CG-SURG-73 |
|
Corneal Collagen Cross Linking |
CG-SURG-79 |
|
Intraocular Telescope |
CG-SURG-81 |
|
Automated Evacuation of Meibomian Gland |
CG-SURG-82 |
|
Correct Intraocular Lenses |
CG-SURG-83 |
|
Viscocanalostomy & Canaloplasty |
CG-SURG-84 |
|
Intraocular Anterior Segment Aqueous Drainage Devices |
CG-SURG-88 |
|
Extracorporeal Shock Wave Therapy |
CG-SURG-95 |
|
Implant of Nerve Stim. Devices |
CG-SURG-96 |
|
Implanted Artificial Iris Devices |
CG-SURG-99MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal |
|
Implanted Port Delivery Systems for Ocular Disease |
MCG: ISC: S-450/450-RRG/5450: Laparotomy for Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy |
|
Implantable Infusion Pumps |
MCG: ISC: S-660/660-RRG: Hysterectomy, Vaginal |
|
Tx for Urinary & Fecal Incontinence |
MCG: ISC: S-665/665-RRG: Hysterectomy, Laparoscopic |
|
Reduction Mammaplasty |
MCG: ISC: S-775/775-RRG: Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy |
|
Mastectomy for Gynecomastia |
MED.00057 |
|
Panniculectomy & Abdominoplasty |
MED.00103 |
|
Regenerative Cell Therapy & Soft Tissue Augmentation |
MED.00132 |
|
Products for Wound Healing & Soft Tissue Grafting |
SURG.00010 |
|
Surg. & Ablative Tx for Chronic Headaches |
SURG.00011 |
|
Intraoperative Assess. of Surgical Margins During Breast-Conserving Surg. |
SURG.00061 |
|
Mandibular/Maxillary Surg. |
SURG.00077 |
|
Blepharoplasty, Repair & Brow Lift |
SURG.00079 |
|
Internal Rib Fixation Systems |
SURG.00084 |
|
Prostate Saturation Biopsy |
SURG.00095 |
|
Focal Laser Ablation for Tx of Prostate Cancer |
SURG.00096 |
|
Penile Prosthesis Implantation |
SURG.00107 |
|
Diaphragmatic/Phrenic Nerve Stim. & Pacing Systems |
SURG.00118 |
|
US Ablation for Oncologic Indications |
SURG.00120 |
|
Radiofrequency Ablation of Renal Sympathetic Nerves |
SURG.00126 |
|
Hysterectomy |
SURG.00132 |
|
Laparoscopic Gynecologic Surgery |
SURG.00135 |
|
Myomectomy |
SURG.00139 |
|
Transurethral Destruction, Prostate Tissue |
SURG.00156 |
|
Nerve Block Therapy for Tx of Headache & Neuralgia |
SURG.00157 |
|
|
SURG.00159 |
|
|
SURG.00160 |
To determine if prior authorization is needed for a member on or after March 1, 2025, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on http://Availity.com to pre‑certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)
Care providers should continue to submit pre‑service review requests to Carelon Medical Benefits Management using the convenient online service provided on the Carelon Medical Benefits Management provider website. The website is available 24 hours a day, seven days a week, and processes requests in real time using Clinical Criteria. To register, go to https://providerportal.com.
For more information
For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:
Cardiovascular Solution | Carelon Insights
Radiology Solution | Carelon Insights
Sleep Solution | Sleep Healthcare | Carelon Insights
Surgical Procedures Solution | Carelon Insights
Radiation Oncology Solution | Carelon Insights
Additional Outpatient Utilization Management
Sign up at provider training for provider training for the additional outpatient UM:
- Wednesday, February 5, 2025, at 12 p.m. ET/11 a.m. CT
- Wednesday, February 12, 2025, at 12 p.m. ET/11 a.m. CT
- Friday, February 21, 2025, at 11 a.m. ET/10 a.m. CT
- Wednesday, February 26, 2025, at 12 p.m. ET/11 a.m. CT
- Wednesday, March 5, 2025, at 12 p.m. ET/11 a.m. CT
Our website, Anthem.com, provides information and tools such as order entry checklists, Clinical Guidelines, and FAQ. You can also contact your provider relationship management representative with any questions.
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.
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CM-076017-24
PUBLICATIONS: March 2025 Provider Newsletter
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