Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM advanced imaging clinical appropriateness guidelines. Part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services

 

Advanced Imaging of the Spine – updates by section

Congenital vertebral defects

  • New requirement for additional evaluation with radiographs

Scoliosis

  • Defined criteria for which pre-surgical planning is indicated
  • Requirement for radiographs and new or progressive symptoms for postsurgical imaging

Spinal dysraphism and tethered cord

  • Diagnostic imaging strategy limiting the use of CT to cases where MRI cannot be performed
  • New requirement for US prior to advanced imaging for tethered cord in infants age 5 months or less

Multiple sclerosis

  • New criteria for imaging in initial diagnosis of MS

Spinal infection

  • New criteria for diagnosis and management aligned with IDSA and University of Michigan guidelines

Axial spondyloarthropathy

  • Defined inflammatory back pain
  • Diagnostic testing strategy outlining radiography requirements

Cervical injury

  • Aligned with ACR position on pediatric cervical trauma

Thoracic or lumbar injury

  • Diagnostic testing strategy emphasizing radiography and limiting the use of MRI for known fracture
  • Remove indication for follow-up imaging of progressively worsening pain in the absence of fracture or neurologic deficits

Syringomyelia

  • Removed indication for surveillance imaging

Non-specific low back pain

  • Aligned pediatric guidelines with ACR pediatric low back pain guidelines

 

Advanced Imaging of the Extremities– updates by section

Osteomyelitis or septic arthritis; myositis

  • Removed CT as a follow up to non-diagnostic MRI due to lower diagnostic accuracy of CT

Epicondylitis and Tenosynovitis – long head of biceps

  • Removed due to lack of evidence supporting imaging for this diagnosis

Plantar fasciitis and fibromatosis

  • Removed CT as a follow up to non-diagnostic MRI due to lower diagnostic accuracy of CT
  • Added specific conservative management requirements

Brachial plexus mass

  • Added specific requirement for suspicious findings on clinical exam or prior imaging

Morton’s neuroma

  • Added requirements for focused steroid injection, orthoses, plan for surgery

Adhesive capsulitis

  • Added requirement for planned intervention (manipulation under anesthesia or lysis of adhesions)

Rotator cuff tear; Labral tear – shoulder; Labral tear - hip

  • Defined specific exam findings and duration of conservative management
  • Recurrent labral tear now requires same criteria as an initial tear (shoulder only)

Triangular fibrocartilage complex tear

  • Added requirement for radiographs and conservative management for chronic tear

Ligament tear – knee; meniscal tear

  • Added requirement for radiographs for specific scenarios
  • Increased duration of conservative management for chronic meniscal tears

Ligament and tendon injuries – foot and ankle

  • Defined required duration of conservative management

Chronic anterior knee pain including chondromalacia patella and patellofemoral pain syndrome

  • Lengthened duration of conservative management and specified requirement for chronic anterior knee pain

Intra-articular loose body

  • Requirement for mechanical symptoms

Osteochondral lesion (including osteochondritis dissecans, transient dislocation of patella)

  • New requirement for radiographs

Entrapment neuropathy

  • Exclude carpal and cubital tunnel

Persistent lower extremity pain

  • Defined duration of conservative management (6 weeks)
  • Exclude hip joint (addressed in other indications)

Upper extremity pain

  • Exclude shoulder joint (addressed in other indications)
  • Diagnostic testing strategy limiting use of CT to when MRI cannot be performed or is non-diagnostic

Knee arthroplasty, presurgical planning

  • Limited to MAKO and robotic assist arthroplasty cases

Perioperative imaging, not otherwise specified

  • Require radiographs or ultrasound prior to advanced imaging

 

Vascular Imaging – updates by section

  • Alternative non-vascular modality imaging approaches, where applicable

Hemorrhage, Intracranial

  • Clinical scenario specification of subarachnoid hemorrhage indication.
  • Addition of Pediatric intracerebral hemorrhage indication.

Horner’s syndrome; Pulsatile Tinnitus; Trigeminal neuralgia

  • Removal of management scenario to limit continued vascular evaluation

Stroke/TIA; Stenosis or Occlusion (Intracranial/Extracranial)

  • Acute and subacute time frame specifications; removal of carotid/cardiac workup requirement for intracranial vascular evaluation; addition of management specifications
  • Sections separated anatomically into anterior/posterior circulation (Carotid artery and Vertebral or Basilar arteries, respectively)

Pulmonary Embolism

  • Addition of non-diagnostic chest radiograph requirement for all indications
  • Addition of pregnancy-adjusted YEARS algorithm

Peripheral Arterial Disease

  • Addition of new post-revascularization scenario to both upper and lower extremity PAD evaluation

 

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 Portal at availity.com.
  • Call the AIM Contact Center toll-free number: 800-554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. ET

 

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.

 

1152-0621-PN-CNT



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June 2021 Anthem Provider News - Missouri