Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Radiology

Brain imaging:

• Added indications for magnetic resonance imaging (MRI) and amyloid beta positron emission tomography (PET) imaging in Alzheimer’s disease to address patients considering or receiving lecanemab

Spine imaging:

• Changed perioperative and periprocedural imaging to postoperative and postprocedural imaging:
  • Pre-procedure requests should be reviewed based on more specific indication.

Extremity imaging:

• Separated criteria for osteomyelitis and septic arthritis into separate indications:
  • US or arthrocentesis as preliminary tests were placed only in the septic arthritis indication.

Vascular imaging:

• Computed tomography angiography (CTA)/magnetic resonance angiography (MRA) head addition for chronic posterior circulation stroke/transient ischemic attack (TIA) presentations (CTA/MRA of the neck is already allowed; an intracranial evaluation is needed for full extent of anatomy).
• Lower extremity peripheral artery disease (PAD): updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with American College of Radiology (ACR) Appropriateness Criteria®
• Suboptimal imaging option downgrades/removals in brain, head, neck, and abdomen/pelvis

Cardiovascular

Imaging of the heart:

• Resting transthoracic echocardiography (TTE)
• Expanded frequency of echocardiographic evaluation in patients on mavacamten for treatment of hypertrophic obstructive cardiomyopathy (HOCM)
• Expanded criteria for echocardiographic evaluation to allow a single screening for cardiac disease in patients undergoing evaluation for solid organ or hematopoietic cell transplant

Cardiac resynchronization therapy:

• Added exclusion for wireless CRT

Diagnostic coronary angiography:

• Criteria reaffirmed — no changes

Endovascular revascularization:

• Added indication for endovascular venous arterialization of the tibial or peroneal veins
• Added exclusions for endovenous femoral-popliteal arterial revascularization with transcatheter placement of intravascular stent and intravascular lithotripsy
• Added exclusion for atherectomy (clarification)

Implantable cardioverter defibrillators (ICD):

• Transvenous ICD placement
• Expanded criteria for transvenous ICD to include phospholamban, filamin-C, and lamin A/C cardiomyopathies

Percutaneous coronary intervention:

• Added exclusion for percutaneous transluminal coronary lithotripsy

Permanent implantable pacemakers:

• Device replacement
• Added criteria for permanent implantable pacemaker device replacement
• Single chamber leadless pacemakers
• Clarified that criteria for single chamber leadless pacemaker apply to the right ventricle
• Added exclusion for right atrial single chamber leadless pacemakers
• Dual chamber leadless pacemakers
• Added exclusion for dual chamber leadless pacemakers

Radiation oncology:

• Removed criteria for hyperthermia
• Clarified inclusion criteria of the radiation therapy oncology (RTOG) 1112 protocol

Sleep disorder management:

• Expanded definitions and terminology
• Expanded documentation of hypoventilation
• Expanded criteria for home and in-lab sleep studies
• Added contraindication to automatic positive airway pressure (APAP) titration for use of supplemental oxygen
• Removed home sleep apnea testing (HSAT) as an option in medical necessity of multiple sleep latency test/maintenance of wakefulness test (MSLT/MWT) for suspected narcolepsy
• Management of obstructive sleep apnea (OSA) using implanted hypoglossal nerve stimulators (HNS): narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by the FDA
• Miscellaneous Devices section added: Electronic positional therapy and neuromuscular electrical training of the tongue musculature are considered not medically necessary due to lack of
  high-quality evidence.

Reminders

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by doing the following:

• Access Carelon Medical Benefits Management’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.

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

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