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

Effective for dates of service on and after September 10, 2023, the following updates will apply to the Carelon Medical Benefits Management Advanced Imaging 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.

Updates by guideline — advanced imaging:

• Imaging of the extremities:
  • Shoulder arthroplasty — clarified that MRI should not be used for preoperative assessment of bone stock and bone version (CT only)
• Imaging of the spine:
  • Spinal infection — added criterion for imaging in patients at risk for infection based on American College of Radiology (ACR) appropriateness criteria
  • Radiculopathy — added indication for CT when being done as a myelogram, based on ACR appropriateness criteria and feedback from subject matter experts
• Vascular imaging:
  • Vascular anatomic delineation prior to procedures — removed exclusions for coronary artery bypass graft (CABG) and open valve replacement/repair
  • Vascular anatomic delineation prior to transcatheter aortic valve implantation (TAVI/TAVE) — allowed CT chest as an alternative to CTA
  • Stenosis or occlusion of extracranial carotid arteries — limited screening for patients with incidentally detected carotid calcification to those undergoing preoperative evaluation for cardiac surgery; modified criteria for management of known stenosis to allow follow-up per American College of Cardiology guidelines
  • Pulmonary hypertension — clarified that criteria are applicable to all causes, not just pulmonary arterial hypertension
  • Unexplained hypotension — removed indication as it is more appropriate for inpatient management
  • Peripheral arterial disease — removed cilostazol as prerequisite therapy; added baseline evaluation and surveillance indications following endovascular revascularization
  • Popliteal artery aneurysm — added diagnosis and management indications; added surveillance for unrepaired aneurysms to align with Society for Vascular Surgery guidelines

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management as follows:

• Access Carelon Medical Benefits Management’s ProviderPortal_SM directly at www.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. 

If you have 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.