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

Effective for dates of service on and after June 15, 2025, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines. As part of the annual guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Musculoskeletal

Interventional pain management:

• Epidural and intradiscal injection procedures and diagnostic selective nerve root blocks — renamed to include intradiscal injections
• Epidural injections — clarified requirement for contrast to confirm needle placement
• Epidural injections — clarified language addressing when a second injection is indicated
• Reworded requirements related to advanced imaging
• Specified that imaging guidance with contrast to confirm needle position is required unless contraindicated — diagnostic selective nerve root block (SNRB)
• Specified requirement for advanced imaging — SNRB
• Clarified that contraindications apply to SNRB as well as epidural steroid injection (ESI)
• Clarified that post‑traumatic back pain contraindication applies only when the trauma is acute —SNRB
• Added contraindication for cases where imaging studies have shown inadequate epidural space for needle placement at the target level — SNRB
• Specifically called out percutaneous intervertebral disc injection of allogeneic cellular and/or tissue‑based product in the exclusions as stated in the new T‑codes listed — epidural and intradiscal injections
• Clarified that this procedure can be done in patients with Type I or Type II modic changes on MRI — intraosseous basivertebral nerve ablation
• Clarified that confirmation of needle position must include contrast unless there is a documented allergy — sacroiliac joint injection
• Increased volume of injection to 2.5 cc — sacroiliac joint injections
• Specified that a repeat sacroiliac joint injection is indicated when prior injection provided relief for at least three months
• Repeat therapeutic intraarticular sacroiliac joint injections — increased number of injections in a 12‑month period from three to four
• Added exclusion for substances other than corticosteroids (with or without local anesthetic) in therapeutic sacroiliac joint injections
• Clarified that PDN refers to painful diabetic neuropathy — spinal cord stimulators
• Specified nonsurgical low back pain as an exclusion — sacroiliac joint injections

As a reminder, ordering and servicing providers may submit preapproval requests to Carelon Medical Benefits Management by accessing Carelon Medical Benefits Management’s ProviderPortalSM at 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 questions related to the guidelines, please email Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com. You may also access and download a copy of the current and upcoming guidelines here.