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

Effective for dates of service on and after November 17, 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.

Musculoskeletal

Joint Surgery

• Reverse Shoulder Arthroplasty:
  • Added a requirement for impaired function for six months for consistency with total shoulder arthroplasty.
  • Removed requirement for conservative management when there is severe osteoarthritis for consistency with other joint replacements.
• Shoulder Arthroscopy and Open Procedures:
  • Removal of loose body — removed requirement for specific findings on exam.
  • Rotator cuff repair and revision — added an exclusion for subacromial balloon spacer due to lack of supporting evidence.
  • Labrum Repair — removed Bankart lesion broadening MRI findings to allow for any labral tear.
  • Chronic shoulder instability or laxity — broadened exam findings to include any evidence of instability rather than just the apprehension/relocation test.
  • Tendinopathy of the long head of the biceps — removed specific exam findings related to long head of biceps pathology.
• Primary Total Hip Arthroplasty:
  • Removed the requirements for conservative management and 3-month duration of symptoms when radiographs show severe osteoarthritis.
• Primary Partial Hip Arthroplasty:
  • Combined criteria for partial hip arthroplasty and partial hip resurfacing
• Hip Arthroscopy:
  • Removal of loose body — removed requirement for specific findings on exam.
• Knee Arthroplasty:
  • Added exclusion for the use of an implantable shock absorber due to lack of supporting evidence.
• Knee Arthroscopy:
  • ACL reconstruction — removed standalone scenario of physically demanding occupation/pattern of activities.
  • Excision of popliteal cyst – Added imaging requirement.
  • Repair of subchondral bone defects (subchondroplasty) — added exclusion for use of engineered calcium phosphate mineral or similar compounds due to lack of supporting evidence.

• Osteochondral Grafts:
  • Juvenile Osteochondritis Dissecans — expanded allowances to include either failed conservative management or unstable lesion.
  • Added exclusion for use of particulated juvenile articular cartilage due to lack of evidence supporting its use.

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.

For 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.