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: Central: 800-554-0580, Monday – Friday, 8:30 a.m. – 7:00 p.m. ET.

 

Please note, this program does not apply to 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.