Updates to AIM Advanced Imaging Clinical Appropriateness Guideline
Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines.
Chest Imaging and Head and Neck Imaging
Hoarseness, dysphonia, and vocal cord weakness/paralysis – primary voice complaint
Require laryngoscopy for the initial evaluation of all patients with primary voice complaint
Brain Imaging and Head and Neck Imaging
- Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is nondiagnostic or unable to be performed.
- Higher allowed threshold for consecutive frequencies to establish SNHL.
- Remove CT brain as an alternative to evaluating hearing loss based on ACR guidance.
Remove sudden onset symmetric tinnitus as an indication for advanced imaging.
Head and Neck Imaging
Add more flexibility for the method of conservative treatment in chronic sinusitis.
Require conservative management prior to repeat imaging for patients with prior sinus CT.
Temporomandibular joint dysfunction
Removed requirement for radiographs/ultrasound.
Cerebrospinal fluid (CSF) leak of the skull base
Added scenario for management of known leak with change in clinical condition.
Ataxia, congenital or hereditary
Combine with congenital cerebral anomalies to create one section.
- More frequent imaging for a watch and wait or incomplete resection.
- New indication for Neurofibromatosis type 2 (NF 2).
- More frequent imaging when MRI shows findings suspicious for recurrence.
- Single post-operative MRI following gross total resection.
- Include pediatrics with known acoustics (rare but NF 2).
Tumor – not otherwise specified
Repurpose for surveillance imaging of low grade neoplasms.
Seizure disorder and epilepsy
- Limit imaging for the management of established generalized epilepsy.
- Require optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy.
Remove response to treatment as a primary headache red flag.
Mental status change and encephalopathy
Added requirement for initial clinical and lab evaluation to assess for a more specific cause.
General enhancements: Updates to Scope/Definitions, general language standardization
General Content enhancements: Overall alignment with current national oncology guideline recommendations, resulting in:
- Removal of indications/parameters not addressed by NCCN.
- Average risk inclusion criteria for CT Colonography.
- New allowances for MRI Abdomen and/or MRI Pelvis by tumor type, liver metastatic disease.
- New indications for Acute Leukemia (CT, PET/CT), Multiple Myeloma (MRI, PET/CT), Ovarian Cancer surveillance (CT), Bone Sarcoma (PET/CT).
- Updated standard imaging pre-requisites prior to PET/CT for Bladder/Renal Pelvis/Ureter, Colorectal, Esophageal/GE Junction, Gastric and Non-Small Cell Lung Cancers.
- Additional PET/CT management scenarios for Cervical Cancer, Hodgkin Lymphoma.
Other content enhancements by section:
- Cancer screening: New indication for Pancreatic Cancer screening.
- Breast Cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment Breast MRI after breast conserving therapy or unilateral mastectomy.
- Prostate Cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE.
- Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI).
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, Monday – Friday, 8 a.m. to 5 p.m. ET.
December 2020 Anthem Provider News - Virginia