Update to AIM Musculoskeletal Joint Surgery Clinical Appropriateness Guidelines

Effective for dates of service on and after June 29, 2019, the following updates will apply to the AIM Joint Surgery Clinical Appropriateness Guidelines.

 

General Requirements

 

• Conservative management: For joint arthroplasty, clarification of conservative management options provide allowance for conservative management exception. Add intraarticular corticosteroid injections as an option. Remove ice or heat given that it is commonly performed in all patients and hence does not meet the threshold for a non-operative management modality as intended. Addition of physical therapy or home therapy requirement for all non-arthroplasty joint procedures based on preponderance of benefit over harm to conservative care. Remove MOON protocol conservative care requirement throughout the document based on feasibility and standards of practice

 

• Reporting of symptom severity: Inability felt too restrictive to allow for difficulty performing

 

• Tobacco Cessation: removed nicotine-free documentation requirement

 

Subacromial Impingement Syndrome (without Rotator Cuff Tear)Cervical Decompression with or without Fusion

• Drop Arm Test removed due to lack of diagnostic accuracy for subacromial impingement

 

Synovectomy/Debridement

• New indication for synovectomy/debridement based on review of the evidence and common clinical scenarios

 

Tendinopathy of the Long Head of the Biceps – Tenodesis or Tenotomy

• Allows both techniques based on no evidence for net benefit of one over the other

• Allow a broader range of clinical symptoms and a lower threshold for imaging evidence of tendinopathy , no requirement for MR evidence as tendinopathy can be a clinical diagnosis

 

Primary Total Hip Arthroplasty

• Addition of fracture management and hip arthrodesis

 

Revision Total Hip Arthroplasty

• Addition of appropriate clinical scenarios based on clinical practice experience and evidence, align terminology to that used in the literature

 

Resection Arthroplasty of the Hip, Femoral Head Ostectomy, or Girdlestone Resection Arthroplasty

• Addition of appropriate clinical scenarios based on clinical practice experience (limited evidence)

 

Hip Arthroscopy

• Expanded appropriate techniques for FAI surgery to include acetabuloplasty and femoroplasty

 

Arthroscopic Treatment of FAIS

• Radiographic and clinical criteria added to include symptoms related to FAI and the likelihood that surgery will be successful

 

Elective Patellofemoral Arthroplasty

• New guideline for patellofemoral arthroplasty, a unicompartmental procedure based on evidence and standards of practice

 

Revision of Prior Knee Arthroplasty

• Addition of appropriate clinical scenarios based on clinical practice experience and evidence, align terminology to that used in the literature

 

Meniscal Repair or Meniscectomy

• Conservative requirement for degenerative meniscus tears

• Definition of acute meniscal tear and symptomatology

• More restrictive use of partial meniscectomy associated with osteoarthritis and degenerative tears

 

Arthroscopically assisted lysis of adhesions

• New guideline based on evidence and clinical consensus

Manipulation under anesthesia

• New guideline based on evidence and clinical consensus

 

In-Office Diagnostic Arthroscopy (mi-eye 2™)

• Not medically necessary based on lack of evidence for net benefit

 

Meniscal Allograft Transplantation of the Knee

• Collagen meniscal implants are considered not medically necessary

 

Treatment of Osteochondral Defects

• New criteria for talar OCD based on lesion size and prior procedures

 

Autologous chondrocyte implantation (ACI)

• Allow patellar surface ACI based on evidence for non-inferiority relative to trochlear surface lesions

 

CPT Code additions

• CPT codes 27120, 27122, 27437, 27445, 27488, 29871, G0428, 28446, and 29892

As a reminder, ordering providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal_SM 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.

 

Please note, this program does not apply to the Blue Cross and Blue Shield Service Benefit Plan – also known as the Federal Employee Program (FEP).

 

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.