Effective for dates of service on and after May 18, 2019, the following updates will apply to the AIM Specialty Health Musculoskeletal Program Clinical Appropriateness Guidelines. 


Spine Surgery - Enhancements as indicated by section below:

General Requirements
-Reporting of symptom severity: expanded to include IADLs as functional impairment

-Tobacco Cessation: removed nicotine-free documentation requirement

Cervical Decompression with or without Fusion
-Added exclusion of cervical/thoracic laminectomy if criteria not met

Lumbar Discectomy, Foraminotomy, and Laminotomy

-Added criteria to define radicular pain for Lumbar herniated intervertebral disc

Lumbar Fusion and Treatment of Spinal Deformity (including scoliosis and Kyphosis)

-Added indication and criteria for Flat back Deformity

-Added criteria for Isthmic spondylolisthesis

-Added indication and criteria for Scheuermann’s Kyphosis

Lumbar Laminectomy

-Added exclusion of lumbar laminectomy if criteria not met

Noninvasive Electrical Bone Growth Stimulation

-Added risk factor criteria for cervical non-invasive bone growth stimulation


Interventional Pain Guidelines - Enhancements as indicated by section below: 


General Requirements

-Reporting of symptom severity: expanded to include IADLs as functional impairment


Therapeutic Epidural Steroid Injection

-Updated time period of initial advanced imaging

-Definition and frequency of repeat therapeutic epidural steroid injection

-Updated maximum number of annual injections

-Added criteria for subsequent injection after suboptimal initial response

 

Paravertebral Facet Injection/Nerve Block/Neurolysis

-Updated injection frequency limitations


Diagnostic Intraarticular Sacroiliac Joint Injections

-Updated pain reduction from initial injection

 

Spinal Cord Stimulators

-Added criteria for revision/removal of spinal cord stimulator

-Separated criteria of trial stimulation and permanent stimulator implantation

-Added exclusion of dorsal root ganglion stimulation

 

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:   866-789-0397;  8 a.m. to 5 p.m. ET.

 

Please note, this program does not apply to the Federal Employee Program (FEP) or National Accounts.

 

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 guidelines here.

 

 



Featured In:
February 2019 Anthem Provider Newsletter - Virginia