Medicare AdvantageMay 16, 2023
Updates to Carelon Medical Benefits Management, Inc. Advanced Imaging, Sleep Disorder Management, and Spine Surgery 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, Inc.* (formerly AIM Specialty Health®) Clinical Appropriateness Guidelines listed below. As part of the Carelon 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 (computed tomography 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 computed tomography angiography (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
Sleep disorder management:
- Home sleep testing — changed terminology from home sleep test/study to home sleep apnea test/study throughout the document
- In-lab sleep studies in adult patients, for follow-up laboratory studies in established sleep disorder — added indication for one-time optimization of device settings after insertion of a phrenic nerve stimulator
- Contraindications to automatic positive airway pressure (APAP) — specified that APAP is contraindicated for chronic obstructive pulmonary disease (COPD) that is moderate or severe
- Bi-level positive airway pressure (BPAP) devices — added indication for patients with obesity hypoventilation syndrome
- Ongoing treatment with positive airways pressure devices APAP, BPAP, or continuous positive airway pressure (CPAP) — specified that demonstration of compliance with therapy is not required for non-adult patients or for patients with disorders other than obstructive sleep apnea or central sleep apnea
- Multiple sleep latency testing and maintenance of wakefulness testing — previous prerequisite for polysomnography was expanded to also allow prior home sleep apnea testing; for idiopathic hypersomnia, modified prerequisite for prolonged night sleep to prolonged sleep during primary sleep period
Spine surgery:
- Cervical decompression:
- Cervical disk arthroplasty for radiculopathy — removed requirement for conservative management when objective neurologic deficits are present; specified that physical therapy is optional for scenarios that do require conservative management
- Cervical decompression for degenerative cervical kyphosis — added indications for debilitating neck pain with functional limitations and clinically significant problems with horizontal gaze, swallowing, or breathing
- Cervical decompression for pseudarthrosis — shorten time required since prior procedure to 6 months (from 9 months)
- Lumbar disc arthroplasty — removed the exclusion for prior spine surgery of any form at the target level to align with FDA approval language
- Lumbar discectomy, foraminotomy, laminotomy for lumbar disc herniation — removed requirement for conservative management when objective neurologic deficits are present; specified that physical therapy is optional for scenarios that do require conservative management; for recurrent disc herniation, shortened conservative management duration to 6 weeks to match that of initial herniation
- Lumbar fusion for isthmic spondylolisthesis — specified that instability must be present; the presence of a pars defect alone is not an indication for fusion
- Lumbar fusion for pseudarthrosis — shorten time required since prior procedure to 6 months (from 9 months)
- Lumbar laminectomy for lumbar synovial cyst — added indication for laminectomy without fusion for synovial cyst (if symptomatic instability is present, existing criteria for fusion would apply)
- Vertebroplasty/kyphoplasty for osteolytic metastasis, myeloma, or plasmacytoma — removed requirement for prior chemo or radiation therapy
- Vertebroplasty/kyphoplasty — new exclusion for prophylactic vertebroplasty in posterior spinal fusion
- Sacroiliac joint fusion — revised posterior (dorsal) minimally invasive surgical (MIS) SI joint fusion procedure description
As a reminder, ordering and servicing providers may submit prior authorization/precertification requests to Carelon by accessing Carelon’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.
If you have questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.
MULTI-BCBS-CR-023577-23-CPN23072
PUBLICATIONS: June 2023 Provider Newsletter
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