Effective for dates of service on and after May 18, 2019, the following updates will apply to the AIM Specialty Health Musculoskeletal Program Clinical Appropriateness Guidelines. 

 

Spine Surgery - Enhancements as indicated by section below: 

  • General requirements
    • Reporting of symptom severity: expanded to include IADLs as functional impairment
    • Tobacco cessation: removed nicotine-free documentation requirement
  • Cervical decompression with or without fusion
    • Added exclusion of cervical/thoracic laminectomy if criteria not met
  • Lumbar discectomy, foraminotomy, and laminotomy
    • Added criteria to define radicular pain for lumbar herniated intervertebral disc
  • Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis)
    • Added indication and criteria for flat back deformity
    • Added criteria for isthmic spondylolisthesis
    • Added indication and criteria for Scheuermann’s kyphosis
  • Lumbar laminectomy
    • Exclusion of lumbar laminectomy if criteria not met
  • Noninvasive electrical bone growth stimulation
    • Added risk factor criteria for cervical non-invasive bone growth stimulation

 

Interventional Pain Guidelines - Enhancements as indicated by section below: 

  • General requirements
    • Reporting of symptom severity: expanded to include IADLs as functional impairment
  • Therapeutic epidural steroid injection
    • Updated time period of initial advanced imaging
    • Definition and frequency of repeat therapeutic epidural steroid injection
    • Updated maximum number of annual injections
    • Added criteria for subsequent injection after suboptimal initial response
  • Paravertebral facet injection/nerve block/neurolysis
    • Updated injection frequency limitations
  • Diagnostic intraarticular sacroiliac joint injections
    • Updated pain reduction from initial injection
  • Spinal cord stimulators
    • Added criteria for revision/removal of spinal cord stimulator
    • Separated criteria of trial stimulation and permanent stimulator implantation
    • Added exclusion of dorsal root ganglion stimulation

 

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

  • Access AIM’s ProviderPortallSM 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: 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m. 

 

Please note, this program does not apply to FEP or National Accounts.

 

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 guidelines here.



Featured In:
February 2019 Anthem Maine Provider Newsletter