Effective December 1, 2020, Anthem Blue Cross and Blue Shield will transition the clinical criteria for medical necessity review of certain rehabilitative services to AIM Specialty Health®* Rehabilitative Service Clinical Appropriateness Guidelines as part of the AIM rehabilitation program. Reviewed services will include certain physical therapy, occupational therapy and speech therapy services.

 

As part of this transition of clinical criteria, the following procedures will be subject to prior authorization as part of the AIM rehabilitation program: 

 

CPT® code

Description

90912

Biofeedback training for bowel or bladder control, initial [15 minutes]

90913

Biofeedback training for bowel or bladder control, additional [15 minutes]

96001

Three-dimensional, video-taped, computer-based gait analysis during walking

0552T

Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional

20560

Needle insertion(s) without injection(s), [1 or 2 muscle(s)]

20561

Needle insertion(s) without injection(s), [3 or more muscle(s)]

97129

One-on-one therapeutic interventions focused on thought processing and strategies to manage activities

97130

Each additional [15 minutes] (List separately in addition to code for primary procedure.)

92609

Therapeutic services for use of speech-generating device with programming

92630

Hearing training and therapy for hearing loss prior to learning to speak

 

The following procedure will be removed from the program:

  • S9117: Back school, per visit

 

Refer to the AIM clinical guidelines for the clinical criteria for the services and a complete list of CPT codes/services that will be included in the AIM Rehabilitation Program. Below are the codes whose statuses are changing, either being added to or removed from the program upon transition from current Anthem guidelines to AIM guidelines. The applicable sub-disciplines (for example, PT, OT, ST) are also noted. Note: evaluation codes will continue not to require prior authorization.

 

What is the step process/clinical pathway details for each service being transitioned?

The general process for requesting services will remain unchanged from the current program. However if a provider intends to do some of the new services/codes included in these guidelines (listed above), they will need to enter those codes in addition to their main treatment codes when submitting a request as several of those services are subject to additional criteria (refer to guideline) and require separate consideration.

 

How many visits are approved on the initial request and recurring requests?

The visit allocation models will remain unchanged from the current program. Visit allocations vary; there is not a set number. While visits are allocated incrementally throughout the episode of care, there is no limit on the total number of visits as long as the requests continue to meet criteria for medical necessity and benefits have not been exhausted. There is also no limit on the number of requests a provider may submit within the episode of care.

 

When is clinical documentation needed?

This will remain unchanged from the current program. Clinical documentation uploads are required on all recurring (for example, third and subsequent) requests.

 

Apart from using the AIM portal effective December 1, 2020 to submit the requests, what additional changes will impact the provider’s experience?

New clinical criteria outlined in the AIM guidelines will be used to make medical necessity determinations, including those pertaining to the newly added services/codes. (See above grid.) The AIM rehabilitation team will be offering robust training related to the new guidelines, with particular emphasis on any changes that providers might encounter, in order to facilitate a smooth transition.

 

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

  • Access AIM 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 portal* at availity.com.
  • Call the AIM toll-free number at 1-800-714-0040 Monday through Friday, 8:30 a.m. to 7 p.m. ET.

 

If you have 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 at aimproviders.com/rehabilitation.

 

* 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.



Featured In:
October 2020 Anthem Provider News - Indiana