CommercialCoverageMedium impact
[New York] Medical Policy and Clinical Guideline updates
Anthem BCBS·NY · Ophthalmology, General Surgery·Medical Policy
Effective date
Jan 1, 2027
We identified it
Jul 31, 2026
Summary
Anthem Blue Cross and Blue Shield is implementing two new clinical guidelines effective January 1, 2027: CG-MED-102 for dichoptic digital therapy for amblyopia and CG-SURG-116 for surgical treatment of hyperhidrosis. These guidelines establish medical necessity criteria that may result in services previously covered being designated as not medically necessary, potentially leading to claim denials.
Action Required
By December 1, 2026: Billing team and providers must obtain and review the full text of guidelines CG-MED-102 and CG-SURG-116 from https://anthem.com/provider (Select For Providers > your state > Resources > Medical Policies & Clinical UM Guidelines). Identify all current claims and encounters involving dichoptic digital therapy devices for amblyopia or endoscopic thoracic sympathectomy for hyperhidrosis. Educate providers on new medical necessity criteria for these services. Update encounter documentation templates and prior authorization processes to align with new criteria. Beginning January 1, 2027, ensure all claims for these services include documentation supporting medical necessity per the new guidelines. Failure to meet the new criteria will result in claim denials and potential recoupment of previously paid claims.