Medicare Advantage

 

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health®* Diagnostic Coronary Angiography and Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Diagnostic coronary angiography:

  • Removed indications for asymptomatic patients (in alignment with the ischemia trial)
  • Facilitated coronary angiography with a view to intervention in non-culprit vessels following
    ST-segment elevation myocardial infarction (STEMI), in alignment with the complete trial
  • For patients undergoing preoperative evaluation for transcatheter aortic valve replacement (TAVR) or other valve surgery, aligned criteria with the updated American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the management of patients with valvular heart disease

 

Percutaneous coronary intervention:

  • Revised criteria such that, for some cohorts, only those patients with persistent unacceptable symptoms and moderate or severe stress test abnormalities can proceed to revascularization (in alignment with the ischemia trial)
  • For non-left main percutaneous coronary intervention (PCI), expanded use to non-culprit vessels in patients following STEMI, and restricted use to those with moderate or severe stress test abnormalities who have failed medical therapy
  • Left main PCI limited to situations where coronary artery bypass grafting (CABG) is contraindicated or refused (in alignment with noble and excel trials)
  • Clarified requirements for patients who have undergone CABG: at least 70% luminal narrowing qualifies as stenosis, symptomatic ventricular tachycardia is considered an ischemic symptom, and instant wave-free ratio fractional flow reserve (iFR) is considered in noninvasive testing
  • Removed requirement to calculate syntax score for patients scheduled to undergo renal transplantation
  • For patients scheduled for percutaneous valvular procedures (e.g., TAVR/TAVI or mitral valve repair), added clarification that PCI should only be attempted for complex triple vessel disease when CABG is not an option

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

  • AIM ProviderPortalSM: 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.
  • Availity Portal*: availity.com
  • AIM Contact Center toll-free number: 800-714-0040, Monday through Friday, 8:00 a.m. to 8:00 p.m. (ET)

 

What if I need assistance?

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 online.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

ABSCRNU-0272-21



Featured In:
November 2021 Anthem Provider News - Georgia