Updates to AIM Specialty Health Musculoskeletal Program clinical appropriateness guidelines

The following updates will be effective for dates of service on and after September 12, 2021. The following updates will apply to the AIM Musculoskeletal Program: Joint Surgery, Spine Surgery, and Interventional Pain Clinical Appropriateness Guidelines. These AIM Specialty Health_®* guideline updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Joint surgery updates by section 

Shoulder arthroplasty:

• Added steroid injection for all joints; exclusion based on panel recommendation.
• Added exclusions for use of xenografts or biologic scaffold for augmentation or bridging reconstruction, use of platelet rich plasma or other biologics, and concomitant subacromial decompression.
• Removed indication for subacromial impingement with rotator cuff tear.

Hip arthroplasty:

• Added exclusion for steroid injection for joint being replaced within the past six weeks.
• Added labral tear indication.

Knee arthroscopy and open procedures:

• Added chondroplasty indication.
• Narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella.
• Added a conservative management and advanced osteoarthritis exclusion to patellar compression syndrome section.

 

Musculoskeletal program: Interventional pain management guideline updates by section

General requirements — conservative management:

• Addition of physical therapy or home therapy requirement and one complementary modality based on preponderance of benefit over harm to conservative care.
• Aligned with approach to conservative management defined in spine and joint surgery guidelines.
• Epidural injection procedures and diagnostic selective nerve root blocks:
• Addition of statement about adherence to the emergency severity index (ESI) procedural best practices established by FDA Safe Use Initiative. Recommendations are intended for provider education and will not be used for adjudication.
• Clarification of intent around requirement for advanced imaging for repeat injections.

Paravertebral facet injection/nerve block/neurolysis:

• Removed indication for four unilateral medial branch blocks per session based on panel consensus
• Procedural clarification restricting use of corticosteroids for diagnostic medial branch block (MBB) based on panel consensus.
• Limited use of intra-articular steroid injection to mechanical disruption of a facet synovial cyst.
• Removed indication for intra-articular steroid injections based on new evidence for lack of efficacy.
• Increased duration of initial radiofrequency neurotomy (RFN) efficacy needed to avoid a MBB to six months based on panel consensus.
• Clarification that MBB or RFN is not medically necessary after spinal fusion.

Spinal cord and nerve root stimulators:

• Clarified inclusion of different stimulation methods for spinal cord stimulation.
• Added new indication for dorsal root ganglion stimulation.
• Clarified exclusions for spinal cord and 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 Portal* at availity.com. Call the AIM Contact Center toll-free number at 800-714-0040, Monday through Friday, from 7 a.m. to 7 p.m. Eastern time.

 

If you have 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.

 

If you have any questions regarding this communication or any other items, you can call Provider Services at 855-558-1443.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

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