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

Effective for dates of service on and after October 20, 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

Brain imaging:

• Added indications for magnetic resonance imaging (MRI) and amyloid beta positron emission tomography (PET) imaging in Alzheimer’s disease to address patients considering or receiving lecanemab

Spine imaging:

• Changed perioperative and periprocedural imaging to postoperative and postprocedural imaging:
  • Pre-procedure requests should be reviewed based on more specific indication.

Extremity imaging:

• Separated criteria for osteomyelitis and septic arthritis into separate indications:
  • US or arthrocentesis as preliminary tests were placed only in the septic arthritis indication.

Vascular imaging:

• Computed tomography angiography (CTA)/magnetic resonance angiography (MRA) head addition for chronic posterior circulation stroke/transient ischemic attack (TIA) presentations:
  • CTA/MRA of the neck is already allowed; an intracranial evaluation is needed for full extent of anatomy.
• Lower extremity peripheral artery disease (PAD):
  • Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with American College of Radiology (ACR) Appropriateness Criteria®
  • Suboptimal imaging option downgrades/removals in brain, head, neck, and abdomen/pelvis

Reminders

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

• Access Carelon Medical Benefits Management’s ProviderPortal_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.

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.