MedicaidPrior AuthHigh impact
[California] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·CA · Plastic Surgery, Pain Management, Oral & Maxillofacial Surgery +7 more·Prior Authorization
Effective date
Aug 18, 2026
We identified it
Jun 13, 2026
Summary
Anthem California has updated 7 medical policies and 12 clinical utilization management guidelines affecting Medicaid members, including changes to prior authorization requirements for cosmetic/reconstructive services, pain management devices, gene therapies, sleep apnea surgery, transplantation, mobility devices, hearing aids, reproductive technology, and bariatric surgery. Some previously covered services may now be found not medically necessary.
Action Required
By August 18, 2026: Billing team must review all 19 updated medical policies and clinical UM guidelines on Anthem's Medical Policies & Clinical UM Guidelines website. Update prior authorization workflows for affected services including cosmetic/reconstructive procedures, electrical stimulation devices, gene therapies, sleep apnea surgeries, mobility devices, hearing aids, reproductive technology services, and bariatric surgery. Train staff on new medical necessity criteria as some previously covered services may now require additional documentation or be denied. Failure to comply with updated guidelines will result in claim denials for Medicaid members.