Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

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 MRI and amyloid beta PET imaging in Alzheimer 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:
  • CTA/MRA Head addition for chronic posterior circulation Stroke/TIA presentations (CTA/MRA neck already allowed, intracranial eval needed for full extent of anatomy)
  • Lower Extremity PAD: Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with ACR Appropriateness Criteria
  • Suboptimal imaging option downgrades/removals in Brain, Head and 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
  • Also added exclusion for atherectomy (clarification)
• Implantable Cardioverter Defibrillators:
  • 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

MSK:

• Sacroiliac Joint Fusion:
  • New medical necessity criteria for open SI joint fusion
  • As an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum
  • As an adjunct to the medical treatment of sacroiliac joint infection/sepsis (for example, osteomyelitis, pyogenic sacroiliitis)
  • For severe traumatic injuries associated with pelvic ring disruption (for example, pelvic ring fractures, acetabular fracture, spinopelvic dissociation)
  • During multi-segment spinal constructs (for example, correction of deformity in scoliosis or kyphosis surgery) extending to the ilium as part of medically necessary lumbar spine fusion procedures
  • Open SI joint fusion is not medically necessary for poorly defined low back pain and sacral insufficiency fractures.
• Spine Surgery:
  • Lumbar Discectomy, Foraminotomy, and Laminotomy
  • Added exclusion for annular closure device
  • Lumbar Laminectomy
  • Expanded timeframe for imaging lumbar disc herniation (9 months) and lumbar spinal stenosis (12 months)

Radiation Oncology:

• Removed criteria for hyperthermia
• Clarified inclusion criteria of the 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 APAP titration for use of supplemental oxygen
• Removed home sleep apnea testing (HSAT) as an option in medical necessity of MSLT/MWT for suspected narcolepsy
• Management of OSA using Implanted Hypoglossal Nerve Stimulators — narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by 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

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

• Access Carelon Medical Benefits Management’s provider portal 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.