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

Effective for dates of service on and after March 23, 2025, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Note: several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications or criteria, and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Advanced Imaging/Radiology

Oncologic Imaging:

• NCCN alignments for cancer screening and tumor-specific indications (see change summary), largely addressing time intervals of screening or surveillance imaging
• Added FDG PET allowances for colorectal cancer and lung cancer (small cell) accounting for nondiagnostic standard imaging

Imaging of the Abdomen and Pelvis:

• Tumor or neoplasm — added requirement for initial evaluation of testicular masses with US
• Endometriosis — removed US requirement for follow-up of patients with established diagnosis
• Obstetric indications — specified that fetal MRI is indicated in second or third trimester
• Diffuse liver disease — removed criteria for LiverMultiScan as an alternative to MR elastography
• Abdominal and/or pelvic pain, undifferentiated — clarified language regarding initial imaging and lab evaluation

Imaging of the Chest:

• Added indication for dyspnea

Radiation Oncology

Radiation Therapy:

• Special treatment procedure and special physics consult — limited the scenarios where special treatment procedure and special physics consult are indicated to more closely align with recent ASTRO guidance
• Breast cancer — reduced the minimum age at which patients with invasive disease meet criteria for accelerated partial breast irradiation (APBI)
• Head and neck cancer — removed indication for neutron therapy as this is no longer routinely used
• Lung cancer — clarified that the maximum number of fractions for SBRT is five in both NSCLC and SCLC
• Oligometastatic extracranial disease — added scenario for oligoprogressive extracranial disease
• Other tumor types:
  • Combined criteria for IMRT, SRS, and SBRT
  • Expanded criteria for SRS and SBRT to include any radiosensitive tumor
• Prostate cancer:
  • Modified number of fractions indicated, due to larger dose given in each individual fraction (no change in total dose to be given)
  • Added scenario for salvage treatment after prostatectomy
  • Added max fraction number for salvage RT

Hydrogel Spacers:

• Expanded the use of hydrogel spacers to include them in patients receiving any form of external beam radiation therapy

Proton Beam Therapy:

• Added clarifying statement that generic case control plan comparison is insufficient and that patient-specific IMRT isodose comparison is required

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by accessing the ProviderPortal_SM 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.

If you have any guideline-related questions, email Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.