Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Effective for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Radiology

Imaging of the heart (all are Material Changes/Amendments to Contract)

Cardiac CT
Cardiomyopathy: Added specificity to establish the basis for the suspicion of ARVD. This change aligns with Cardiac MRI guidelines.

Resting transthoracic echocardiography (TTE) Evaluation of ventricular function: New indications for evaluation of patients on mavacamten for treatment of HOCM

Imaging of the abdomen and pelvis (all are Material Changes/Amendments to Contract)

Biliary tract dilatation or obstruction: Added indication for annual surveillance in Caroli disease/syndrome based on a 2022 guideline recommendation.

Diffuse liver disease: Removed indication for LiverMultiScan in hemochromatosis as there is insufficient evidence that this provides an advantage over standard MRI for this condition
Osteomyelitis: Added requirement for initial evaluation with radiographs in adult patients based on ACR appropriateness criteria.

Septic arthritis: Added requirement for initial radiographs in adult patients based on ACR appropriateness criteria Pancreatic mass, indeterminate cystic (IPMN/IPMT): For enlarging lesions in patients age 80 or greater, increased surveillance frequency to annually and removed endpoint of 4 years.

Pelvic floor disorders: Added indication for MRI (MR defecography preferred) in suspected pelvic organ prolapse based on ACR appropriateness criteria

Transplant-related imaging: Added indication for single CT abdomen or abdomen/pelvis prior to lung, kidney, or stem cell transplant to align with CT chest guidelines.

Imaging of the brain (not a Material Change/Amendment to Contract)

Movement disorders (Adult only): Added indication for CT head for assessment of skull density prior to MRgFUS for essential tremor

Trauma: Added a 3-6 week follow up study in patients age 6 or younger with stable or inconclusive exam, due to difficulty in accurately assessing for changes in neurologic status
Acoustic neuroma: Added long-term follow-up intervals based on specialty society guidelines

Imaging of the chest (not a Material Change/Amendment to Contract)

Perioperative or periprocedural evaluation, not otherwise specified
Added indication for CT chest to be used for planning of biopsy or placement of fiducial markers using navigational bronchoscopy

Imaging of the head and neck (not a Material Change/Amendment to Contract)

Acoustic neuroma: Added long-term follow-up intervals based on specialty society guidelines
Localized facial pain (including trigeminal neuralgia): Added MRI orbit/face/neck for this indication based on ACR criteria; some facilities use MRI face rather than brain for this condition

Oncologic imaging (all are Material Changes/Amendments to Contract)

Cancer screening

Breast cancer screening
Addition of high-risk genetic mutations (NCCN alignment citing absolute risk of 20% or greater)

Lung cancer screening
Clarification of asbestos-related lung disease as risk factor independent of smoking, aligned with original intent.

Pancreatic cancer screening
Alignment with NCCN recommended parameters; changes are overall expansive, except for:
Older start age (from 45 to 50) for certain genes (ATM, BRCA1, BRCA2, MLH1, MSH2, MSH6, EPCAM, PALB2, TP53)
Family history alone (relative requirement)

Breast cancer
CT chest, CT abdomen and pelvis: Added diagnostic workup allowance when metastatic disease is clinically suspected at presentation

MRI breast: Addition/clarification of surveillance scenarios aligned with NCCN/ACR considerations

FDG-PET/CT: Added allowance for RT planning locoregional recurrence (for example, confirmation of regional nodal involvement)
18F-fluoroestradiol (18F-FES) PET/CT: Added that it Is not indicated due to uncertain net benefit; low-level evidence, insufficient data on outcomes.

Cervical cancer
FDG-PET/CT: Update for follow-up of disease treated with either adjuvant RT or chemoradiation (NCCN alignment).

Hepatocellular and biliary tract cancers
FDG-PET/CT: Removed routine preop PET/CT for biliary tract cancers (NCCN alignment)

FDG-PET/CT: Added management allowance when standard imaging cannot be done or is nondiagnostic (NCCN "consider" for equivocal finding)

Lung cancer – non-small cell
FDG-PET/CT: Added management allowance when recurrence demonstrated by surveillance imaging (NCCN alignment)

Lung cancer – small cell
FDG-PET/CT: Clarification of initial staging allowance (NCCN alignment)

Lymphoma – Non-Hodgkin and leukemia
FDG-PET/CT: NCCN alignment for interim restaging (allowed for DLBCL stage I-IV with or without bulky disease)

Melanoma
Added surveillance option with MRI abdomen for liver metastases.

Prostate cancer
18F Fluciclovine PET/CT or 11C Choline PET/CT, 68GaProstate-specific membrane antigen (PSMA) PET/CT or 18F-DCFPyL (piflufolastat or Pylarify) PET/CT
Addition of diagnostic workup/initial staging indication.
Specification of androgen-receptor pathway inhibitor treatment in alignment with Carelon Medical Benefits Management Inc. Radiation Oncology Guidelines.

Sarcomas of bone/soft tissue
FDG-PET/CT: Added allowance when standard imaging nondiagnostic or contraindicated (bone/soft tissue sarcoma).

Radiation oncology

IMRT for colon cancer (not a Material Change/Amendment to Contract)
New indication for adjuvant treatment of locally advanced adenocarcinoma of the cecum.

SBRT for Hepatocellular Carcinoma (not a Material Change/Amendment to Contract)
Modify eligibility criteria to match clinical trial RTOG 1112

EBRT/IMRT for prostate cancer (not a Material Change/Amendment to Contract)
Adjust for 2 Gy fractions. The total allowed

Musculoskeletal: interventional pain management (all are Material Changes/Amendments to Contract)

Epidural injection procedures and diagnostic selective nerve root blocks
Added osteoporotic fracture as a contraindication because of increased risk of fracture and confounding source of pain.

Therapeutic intraarticular facet joint injections
Added exclusions for use of endoscopic neurolysis or rhizotomy, Diagnostic medial branch blocks, therapeutic intraarticular facet joint injections, and radiofrequency neurotomy when performed at C0-C1 or at C1-C2, and Platelet-rich plasma injection

Spinal cord and dorsal root ganglion stimulators
Added indication of PDN for spinal cord stimulation with strict criteria. Added clarifications.

Sacroiliac joint fusion
Revised exclusion to include procedures that use a transfixing device.

Rehabilitative services (all are Material Changes/Amendments to Contract)

Physical therapy, occupational therapy, speech therapy

Adjunctive & alternative treatments physical therapy
Added Fluidotherapy as an exclusion.
Removed the following services from the list of Exclusions: Active Therapeutic Movement®, Interactive metronome®, MEDEK (Dynamic Method of Kinetic Stimulation)®, Whole body advanced exercise, and Whole body vibration 

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management using the following: 

• Access Carelon Medical Benefits Management Portal_SM 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.

For questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.