Carelon Medical Benefits Management, Inc. updates

Effective on January 30, 2025, the following Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines updates will be adopted for Summit Community Care. This article is to communicate the plan adoption of these Clinical Appropriateness Guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement or site of care review requirement for these services will be implemented, a separate notice will be distributed before the addition of any such prior authorization or site of care review requirement.

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

• Cardiovascular:
  • Implantable Cardioverter Defibrillators
• Genetic Testing:
  • Cell-free DNA Testing for the Management of Cancer
  • Prenatal Testing using cell-free DNA
  • Somatic Tumor Testing
• Musculoskeletal:
  • Joint Surgery
  • Small Joint Surgery
• Site of Care:
  • Site of Care for Advanced Imaging
  • Rehabilitative Site of Care
  • Surgical Site of Care

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

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