Please note, this communication applies to Anthem HealthKeepers Plus offered by HealthKeepers, Inc.

 

The following updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging for claims with dates of service on and after March 14, 2021.

 

Chest imaging, and head and neck imaging

 

Hoarseness, dysphonia and vocal cord weakness/paralysis — primary voice complaint:

  • Required laryngoscopy for the initial evaluation of all patients with primary voice complaint

 

Brain imaging, and head and neck imaging

 

Hearing loss:

  • Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is non-diagnostic or unable to be performed

  • Higher allowed threshold for consecutive frequencies to establish sensorineural hearing loss

  • Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance

 

Tinnitus:

  • Removed sudden onset symmetric tinnitus as an indication for advanced imaging

 

Head and neck imaging

 

Sinusitis/rhinosinusitis:

  • Added more flexibility for the method of conservative treatment in chronic sinusitis

  • Required 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

 

Brain imaging

 

Ataxia, congenital or hereditary:

  • Combined with congenital cerebral anomalies to create one section

 

Acoustic neuroma:

  • More frequent imaging for a watch and wait or incomplete resection

  • New indication for neurofibromatosis type 2 (NF 2)Neurofibromatosis type 2

  • More frequent imaging when MRI shows findings suspicious for recurrence

  • Single post-operative MRI following gross total resection

  • Included pediatrics with known acoustics (rare but NF 2)

 

Tumor — not otherwise specified:

  • Repurposed for surveillance imaging of low grade neoplasms

 

Seizure disorder and epilepsy:

  • Limited imaging for the management of established generalized epilepsy

  • Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy

 

Headache:

  • Removed response to treatment as a primary headache red flag

  • Include pregnancy as a red flag risk factor

 

Mental status change and encephalopathy:

  • Added requirement for initial clinical and lab evaluation to assess for a more specific cause

 

Oncologic imaging

 

General enhancements — Updates to Scope/Definitions, general language standardization

 

General content enhancements — Overall alignment with current National Comprehensive Cancer Network (NCCN) 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 prerequisites prior to PET/CT for bladder/renal pelvis/ureter, ectal, 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 Specialty Health®* (AIM) in one of several ways:

 

 

  • Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. CT.

 

If you have questions related to guidelines, please contact AIM by 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 HealthKeepers, Inc. Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

 

AVA-NU-0305-20



Featured In:
January 2021 Anthem Provider News - Virginia