Update to AIM Musculoskeletal Program Clinical Appropriateness Guidelines

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 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;  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.