Updates to AIM musculoskeletal program clinical appropriateness guidelines

Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM musculoskeletal program: joint surgery and spine surgery clinical appropriateness guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

 

Joint Surgery – updates by section

• Further defined criteria for home physical therapy
• Removed cognitive behavioral therapy as a conservative care modality for extremity
• Added indication for diagnostic arthroscopy
• Standardized radiographic criteria to align with lateral release criteria
• Adhesive capsulitis – added history of trauma or post-operative contracture as a requirement
• Tendinopathy – removed rotator cuff tear as a criterion for tenodesis/tenotomy in patients with a clinical exam who do not meet criteria for SLAP repair or have suggestive MRI findings
• Hip athroscopy – removed complementary alternative medicine as not typically done for the hip
• Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) – removed age as an exclusion for FAIS but further define radiographic exclusions
• Unicompartmental knee arthroplasty/partial knee replacement – added degenerative change of the patellofemoral joint as a contraindication
• Arthroscopically assisted lysis of adhesions – added ligamentous or joint reconstruction criteria
• Added criteria for plica resection

 

Spine Surgery – updates by section

• Further defined criteria for home physical therapy
• Added standard conservative management requirement for instability to align with spinal stenosis indications
• Added new comprehensive indication for tethered cord syndrome

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortalSM directly 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.
• Access AIM via the Availity web portal at availity.com.
• Call the AIM Contact Center toll-free number: 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

 

1153-0621-PN-GA