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

Effective for dates of service on and after August 1, 2025, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. These updates are part of the annual review process to promote clinically appropriate, safe, and affordable healthcare services.

Genetic testing

Chromosomal microarray analysis:

• Added neonatal death to the list of indications considered medically necessary.
• Added new section for Optical Genome Mapping (OGM) to clarify as not medically necessary.

Whole Exome Sequencing (WES) and Whole Genome Sequencing:

• Clarified and restructured the criteria for improved readability.
• Added Medically Necessary criteria for Prenatal and PostNatal testing
• Added Not Medically Necessary statement for early neonatal death
• Added note that WES may include comparator testing.

Pharmacogenomic testing:

• Deleted typo (“one” before “genotyping”) in first sentence
• Added “considered medically necessary for genotyping” to title of Table 1
• Added donanemab‑azbt for neurolytic genotyping for treatment of Alzheimer’s disease
• Added deuruxolitinib for dermatologic genotyping for treatment of alopecia areata
• Added NUDT15 risk allele for hematologic genotyping for thiopurine‑related myelosuppression risk in Asians and Hispanics
• Clarified therapeutic area for Eliglustat as related to hematology rather than pediatrics

Predictive and prognostic polygenic testing:

• Updated Description/Scope and Rationale and added References

Musculoskeletal

Interventional pain management:

• Epidural and intradiscal injection procedures — renamed to include intradiscal injections; clarified requirement for contrast to confirm the needle placement; clarified language addressing when a second injection is indicated; reworded requirements related to advanced imaging.
• Diagnostic selective nerve root block (SNRB) — specified that imaging guidance with contrast to confirm needle position is required unless contraindicated; specified requirement for advanced imaging; clarified that post‑traumatic back pain contraindication applies only when the trauma is acute; added contraindication for cases where imaging studies have shown inadequate epidural space for needle placement at the target level.
• Exclusions:
• Added percutaneous intervertebral disc injection of allogeneic cellular and/or tissue‑based products to the exclusions section for epidural and intradiscal procedures and diagnostic selective root blocks.
• Excluded substances other than corticosteroids (with or without local anesthetic) in therapeutic SI joint injections.
• Intraosseous basivertebral nerve ablation — clarified that this procedure can be done in patients with Type I or Type II Modic changes on magnetic resonance imaging (MRI).
• Sacroiliac joint (SI) injections — clarified that confirmation of needle position must include contrast unless there is a documented allergy:
• Increased volume of injection to 2.5 cc, specified that a repeat SI joint injection is indicated when prior injection provided relief for at least 3 months
• Increased number of repeat therapeutic intraarticular SI joint injections in a 12‑month period from 3 to 4.
• Spinal cord stimulators — clarified that PDN refers to painful diabetic neuropathy:
• Specified nonsurgical low back pain as an exclusion.

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

• Access the Carelon Medical Benefits Management provider portal directly at www.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.

For questions related to guidelines, please email Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines on the Carelon Medical Benefits Management website by visiting guidelines.carelonmedicalbenefitsmanagement.com.