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
    • Added 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 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: Central: 800-554-0580, Monday – Friday, 8:30 a.m. – 7:00 p.m. ET.

 

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 Missouri Provider Newsletter