State & FederalMedicaidMay 1, 2021

Updates to the AIM Specialty Health musculoskeletal program clinical appropriateness guidelines

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).

 

Effective for dates of service on and after September 12, 2021, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines. Part of the AIM Specialty Health®* (AIM) guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe and affordable healthcare services.

 

Joint surgery (updates by section):

  • Further defined criteria for home physical therapy.
  • Removed cognitive behavioral therapy as a conservative care modality for extremity.
  • Added indication for diagnostic arthroscopy.
  • Standardized radiographic criteria to align with lateral release criteria.
  • Adhesive capsulitis — Added history of trauma or postoperative contracture as a requirement.
  • Tendinopathy — Removed rotator cuff tear as a criterion for tenodesis/tenotomy in patients with a clinical exam who do not meet criteria for superior labral tear anterior to posterior repair or have suggestive MRI findings.
  • Hip athroscopy — Removed complementary alternative medicine as not typically done for the hip.
  • Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) — Removed age as an exclusion for FAIS, but further defined radiographic exclusions.
  • Unicompartmental knee arthroplasty/partial knee replacement — Added degenerative change of the patellofemoral joint as a contraindication.
  • Arthroscopically assisted lysis of adhesions — Added ligamentous or joint reconstruction criteria.
  • Added criteria for plica resection.

 

Spine surgery (updates by section):

  • Further defined criteria for home physical therapy.
  • Added standard conservative management requirement for instability to align with spinal stenosis indications.
  • Added new comprehensive indication for tethered cord syndrome.

 

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 www.availity.com.
  • Call the AIM Contact Center toll-free number at 1-800-714-0040 between 7 a.m. and 7 p.m. Eastern time.

 

Questions

If you have 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.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield. Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield.

 

NYE-NU-0305-21 March 2021

517808MUPENMUB

 

PUBLICATIONS: May 2021 Newsletter