Nov 1, 2019 • Products & Programs

Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Musculoskeletal Program Spine Surgery Clinical Appropriateness Guidelines.

 

  • Conservative management – all sections
    • Addition of physical therapy or home therapy requirement and one complementary modality for all spine procedures based on preponderance of benefit over harm to conservative care
  • Lumbar disc arthroplasty
    • Changed the duration of conservative management from 1 year to 6 months based on the FDA prospective study that was done to approve the lumbar disc arthroplasty procedure
    • Added age, level requirements, and symptom/sign requirement and clarified contraindications in reflect these changes
    • Added exclusions criteria of Prior spine surgery of any form at the target level
  • Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis)
    • Inclusion for implant failure similar to cervical spine
    • Consolidated juvenile and congenital in adolescent idiopathic
    • Decreased duration of conservative management required based on lower evidence for efficacy in spinal stenosis and specialty panel feedback
    • Excluded anterior lumbar interbody fusion for foraminal stenosis without evidence of instability exclusion due to very low quality evidence for efficacy
  • Lumbar laminectomy
    • Decreased duration of conservative care required for known spinal stenosis based on guidance from NASS and less evidence for efficacy of conservative management in this population
    • Aligned conservative care duration with discectomy criteria
    • Added new indication for synovial cyst
  • Noninvasive electrical bone growth stimulation
    • Clarification of guideline intent
    • Allow active nicotine use as a risk factor in lumbar uses of bone growth stimulation
    • Allow thoracic fusion similar to lumbar
  • Bone graft substitutes and bone morphogenetic proteins
    • Allow active nicotine use as a risk factor for pseudoarthrosis in graft failure

 

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 at 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.

 

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.


Featured In:
November 2019 Anthem Maine Provider News