*Material adverse change

This communication applies to the Commercial, Medicaid, and Medicare Advantage programs for Anthem Blue Cross and Blue Shield in Wisconsin.

 

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health®* (AIM) Advanced Imaging 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 healthcare services.

 

Updates by guideline

  • Imaging of the Brain:
    • Meningioma — Added more frequent surveillance for WHO grade II/III
    • Bell’s palsy — Limited the use of CT to scenarios where MRI cannot be performed
    • Seizure disorder — Added indication for advanced imaging in pediatric patients with nondiagnostic electroencephalogram (EEG)
  • Imaging of the Head and Neck:
    • Perioperative imaging — Added indication for imaging prior to facial feminization surgery
  • Imaging of the Chest:
    • Perioperative imaging — Added indication for imaging prior to lung volume reduction procedures
    • Imaging abnormalities — Added indication for evaluation of suspected tracheal or bronchial pathology
  • Imaging of the Abdomen/Pelvis:
    • Uterine leiomyomata — Added indication for advanced imaging when ultrasound suggests leiomyosarcoma
    • Pancreatic indications — Added indication for pancreatic duct dilatation
    • Pancreatic mass — Added allowance for more frequent follow up of lesions with suspicious features or in high-risk patients
    • Pancreatitis — Removed allowance for MRI following nondiagnostic CT
    • Pelvic floor disorders — Added indication for MRI pelvis in chronic constipation when preliminary testing is nondiagnostic
    • Abdominal/pelvic pain, undifferentiated — Removed indication for MRI following nondiagnostic CT
  • Oncologic Imaging:
    • National Comprehensive Cancer Network annual alignments for breast cancer screening and the following: Cervical, Head and Neck, Histiocytic Neoplasms, Lymphoma (Non-Hodgkin and Leukemia), Multiple Myeloma, Thoracic, and Thyroid cancers
    • Prostate Cancer:
      • Updated respective conventional imaging prerequisites for 18F Fluciclovine/11C PET/CT and 68Ga PSMA/18F-DCFPyL PET/CT, based on utility of conventional imaging at various PSA thresholds (and removal of low-risk disease waiver from conventional imaging footnote).
      • Addition of 68Ga PSMA or 18F-DCFPyL PET/CT indication aligned with FDA-approved use of Pluvicto (radioligand) treatment for metastatic castrate-resistant disease

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM’s ProviderPortalSM 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.

 

For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.
WIBCBS-CDCRCM-012946-22-CPN11942



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January 2023 Anthem Provider News - Wisconsin