Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines effective October 20, 2024

This article is to communicate the plan adoption of the below Carelon Medical Benefits Management, Inc. guidelines. This does not equate to the presence of a prior authorization requirement. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

Effective on October 20, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates for medical necessity review, will apply for Anthem:

• Cardiology:
  • Cardiac Resynchronization Therapy
  • Endovascular Revascularization
  • Imaging of the Heart
  • Implantable Cardioverter Defibrillators
  • Percutaneous Coronary Intervention
  • Permanent Implantable Pacemakers
• Genetic Testing:
  • Pharmacogenomic Testing
  • Predictive and Prognostic Polygenic Testing
  • Chromosomal Microarray Analysis
  • Whole Exome Sequencing and Whole Genome Sequencing
  • Somatic Tumor Testing
• Musculoskeletal:
  • Spine Surgery
  • Sacroiliac Joint Fusion
• Radiology:
  • Imaging of the Spine
  • Imaging of the Extremities
  • Vascular Imaging
  • Imaging of the Brain

• Sleep:
  • Sleep Disorder Management

Please share this notice with other members of your practice and office staff.