Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Musculoskeletal Program Spine Surgery Clinical Appropriateness Guidelines.

 

  • Conservative management – all sections
    • Addition of physical therapy or home therapy requirement and one complementary modality for all spine procedures based on preponderance of benefit over harm to conservative care
  • Lumbar Disc Arthroplasty
    • Changed the duration of conservative management from 1 year to 6 months based on the FDA prospective study that was done to approve the lumbar disc arthroplasty procedure
    • Added age, level requirements, and symptom/sign requirement and clarified contraindications in reflect these changes
    • Added exclusions criteria of Prior spine surgery of any form at the target level
  • Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
    • Inclusion for implant failure similar to cervical spine
    • Consolidated juvenile and congenital in adolescent idiopathic
    • Decreased duration of conservative management required based on lower evidence for efficacy in spinal stenosis and specialty panel feedback
    • Excluded anterior lumbar interbody fusion for foraminal stenosis without evidence of instability exclusion due to very low quality evidence for efficacy
  • Lumbar Laminectomy
    • Decreased duration of conservative care required for known spinal stenosis based on guidance from NASS and less evidence for efficacy of conservative management in this population
    • Aligned conservative care duration with discectomy criteria
    • Added new indication for synovial cyst
  • Noninvasive Electrical Bone Growth Stimulation
    • Clarification of guideline intent
    • Allow active nicotine use as a risk factor in lumbar uses of bone growth stimulation
    • Allow thoracic fusion similar to lumbar
  • Bone Graft Substitutes and Bone Morphogenetic Proteins
    •  Allow active nicotine use as a risk factor for pseudoarthrosis in graft failure

 

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 Web Portal at Availity.com
  • Call the AIM Contact Center toll-free number 800-554-0580, Monday – Friday, 8:30 a.m. – 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.

 

* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.

 



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November 2019 Anthem Provider News - Ohio