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:  866-789-0397, Monday–Friday, 8 a.m. to 5 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 AIM guidelines.

 

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

 



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November 2019 Anthem Provider News - Virginia