Updates to Carelon Medical Benefits Management, Inc. Advanced Imaging and Sleep Disorder Management Clinical Appropriateness Guidelines

Effective for dates of service on and after September 10, 2023, the following updates will apply to the Clinical Appropriateness Guidelines listed below from Carelon Medical Benefits Management, Inc.* As part of the Carelon Medical Benefits Management, Inc. guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by Guideline

Advanced Imaging:

• Imaging of the Extremities:
  • Shoulder arthroplasty – clarified that MRI should not be used for preoperative assessment of bone stock and bone version (CT only)
• Imaging of the Spine:
  • Spinal infection – added criterion for imaging in patients at risk for infection based on American College of Radiology (ACR) appropriateness criteria
  • Radiculopathy – added indication for CT when being done as a myelogram, based on ACR appropriateness criteria and feedback from subject matter experts
• Vascular Imaging:
  • Vascular anatomic delineation prior to procedures – removed exclusions for coronary artery bypass graft (CABG) and open valve replacement/repair
  • Vascular anatomic delineation prior to transcatheter aortic valve implantation (TAVI/TAVE) – allowed CT chest as an alternative to CTA
  • Stenosis or occlusion of extracranial carotid arteries – limited screening for patients with incidentally detected carotid calcification to those undergoing preoperative evaluation for cardiac surgery; modified criteria for management of known stenosis to allow follow-up per American College of Cardiology guidelines
  • Pulmonary hypertension – clarified that criteria are applicable to all causes, not just pulmonary arterial hypertension
  • Unexplained hypotension – removed indication as it is more appropriate for inpatient management
  • Peripheral arterial disease – removed cilostazol as prerequisite therapy; added baseline evaluation and surveillance indications following endovascular revascularization
  • Popliteal artery aneurysm – added diagnosis and management indications; added surveillance for unrepaired aneurysms to align with Society for Vascular Surgery guidelines

Sleep Disorder Management:

• Home Sleep Testing – changed terminology from home sleep test/study to home sleep apnea test/study throughout the document
• In-Lab Sleep Studies in Adult Patients, for follow-up laboratory studies in established sleep disorder – added indication for one-time optimization of device settings after insertion of a phrenic nerve stimulator
• Contraindications to automatic positive airway pressure (APAP) – specified that APAP is contraindicated for Chronic Obstructive Pulmonary Disease (COPD) which is moderate or severe
• Bi-Level Positive Airway Pressure (BPAP) Devices – added indication for patients with obesity hypoventilation syndrome
• Ongoing treatment with positive airways pressure devices APAP, BPAP, or continuous positive airway pressure (CPAP) – specified that demonstration of compliance with therapy is not required for non-adult patients or for patients with disorders other than obstructive sleep apnea or central sleep apnea
• Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing – previous prerequisite for polysomnography was expanded to also allow prior home sleep apnea testing; for idiopathic hypersomnia, modified prerequisite for prolonged night sleep to prolonged sleep during primary sleep period

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management, Inc. in one of several ways:

• Access the Carelon Medical Benefits Management, Inc. ProviderPortal_SM directly at www.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 Carelon Medical Benefits Management, Inc. via Availity Essentials* at www.availity.com.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management, Inc. via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

On March 1, 2023, AIM Specialty Health began operating as Carelon Medical Benefits Management, Inc.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at
800-901-0020.