Carelon Medical Benefits Management, Inc Updates

Effective on November 30, 2024, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guideline updates will be adopted for Anthem. This article is to communicate the plan adoption of these Carelon Medical Benefits Management guidelines. Existing prior authorization requirements have not changed. 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.

You may access and download a copy of the current and upcoming guidelines here.

• Radiology:
  • Oncologic Imaging

The above guideline updates have a publish date of April 14, 2024.

• Cardiology:
  • Imaging of the Heart
• 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:
  • Vascular Imaging
  • Imaging of the Brain

The above guideline updates have a publish date of October 20, 2024.

• Genetic Testing:
  • Cell-free DNA Testing for the Management of Cancer
  • Prenatal Testing using cell-free DNA
  • Somatic Tumor Testing
• Musculoskeletal:
  • Joint Surgery

The above guideline updates have a publish date of November 17, 2024.

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