*Material Adverse Change (MAC)

 

Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health musculoskeletal clinical appropriateness guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

 

Updates by guideline

Spine surgery:

  • Lumbar disc arthroplasty – add indication for 2-level lumbar disc arthroplasty when using a 2-level FDA-approved implant
  • Lumbar discectomy – remove exclusion for annular closure devices (note: medical necessity of the implant is determined by health plan medical policy)
  • Lumbar fusion – remove exclusion for anterior lumbar interbody fusion for indirect lumbar decompression in the absence of instability
  • Cervical decompression with or without Fusion – add criteria for when revision or replacement may be medically necessary
  • Cervical disc arthroplasty – add criteria for when revision or replacement may be medically necessary
  • Two-level cervical disc arthroplasty – add indication for second level arthroplasty when prior arthroplasty already performed
  • Lumbar disc arthroplasty – add requirement to manage underlying psychiatric disorder; add contraindications including prior fusion, poorly managed psychiatric disorder, chronic radiculopathy; add exclusion for prior lumbar fusion
  • Scheurmann’s kyphosis – removed “associated neurological deficits” as a clinical consideration 
  • Scoliosis – expand indication to include thoracic for progressive adolescent idiopathic scoliosis; increased Cobb angle for skeletally mature patients to greater than 50 degrees 
  • Spinal stenosis – require surgeon’s interpretation of flexion-extension lateral spine x-ray documented in the medical record; added indications for recurrent stenosis, adjacent-level stenosis after a prior fusion, and planned indirect decompression via anterior approach decompression via anterior approach

 

Joint surgery:

  • Total shoulder arthroplasty – add fracture indication for total shoulder arthroplasty (although reverse total shoulder arthroplasty is preferred) to align with AAOS feedback
  • Total shoulder arthroplasty – add exception for Kellgren-Lawrence grade 4 to be consistent with total knee and total hip arthroplasty
  • Hemiarthroplasty – added indications for hemiarthroplasty for glenohumeral arthritis with irreparable rotator cuff and for malignancy involving the glenohumeral joint or surrounding soft tissue
  • Reverse shoulder arthroplasty – add indication when glenoid bone stock inadequate to support anatomic glenoid prosthesis
  • Labrum repair – remove requirement that MRI-demonstrated SLAP lesion is traumatic in nature
  • Adhesive capsulitis – match requirements in knee arthroscopy; reduce timeframe of conservative management to 6 weeks post-surgery for lysis of adhesions/capsular release and MUA
  • Total knee arthroplasty – add patellofemoral osteoarthritis as an indication for total knee arthroplasty
  • Knee arthroscopy – new indication for abrasion arthroplasty/microfracture
  • Knee/arthroscopically assisted lysis of adhesions – remove 12-week post-surgery requirement
  • Knee/manipulation under anesthesia – remove 12-week post-surgery requirement
  • Treatment of osteochondral defects – remove BMI 35 or less from patient selection criteria
  • Autologous chondrocyte implantation – Added contraindications from MACI package insert, including severe osteoarthritis, inflammatory joint disease, knee surgery other than biopsy or MACI preparation, and inability to cooperate with postoperative rehab program

 

Small joint surgery:

  • Hallux rigidus – add criteria for select implant arthroplasties in great toe; remove exclusion for percutaneous osteotomy
  • Hallux valgus/bunionette – remove exclusion for implant arthroplasties
  • Lesser toe deformities – remove exclusions for implant arthroplasties and intramedullary fixation devices
  • First metatarsophalangeal joint arthrodesis – remove requirement for 6 months of symptoms
  • First metatarsophalangeal joint arthroplasty – new indication
  • Hallux rigidus/exclusions – clarified specific types of excluded implants; excluded metatarsophalangeal joint arthroplasties for any other indications; excluded peripheral neuropathy/Charcot joint

 

Sacroiliac joint (SU) fusion:

  • Expand indication to include any FDA-approved minimally invasive/percutaneous SI joint fusion device with fixation
  • Require a trial of at least one therapeutic intra-articular SI joint injection
  • New criteria for revision minimally invasive SI joint fusion
  • Add exclusion for posterior (dorsal) minimally invasive SI joint fusion procedures using only bone grafts and no internal fixation device

 

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: 833-342-1253, Monday through Friday, from 8:30 a.m. to 7:00 p.m. Eastern time

 

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 guidelines here.

 

1724-0522-PN-CNT



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