Effective November 1, 2024
Alpha-1 Proteinase Inhibitors, 5.01.624 PBC | Premera HMO
Site of service review added
- The following will be reviewed for site of service when requested in an inpatient setting:
- Aralast NP
- Glassia
- Prolastin-C
- Zemaira
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523 PBC | Premera HMO
Drugs added
- The following will be reviewed for site of service when requested in an inpatient setting:
- Aralast NP
- Glassia
- Prolastin-C
- Zemaira
Effective October 20, 2024
Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
(formerly AIM Specialty Health).
Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Radiology Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by section
Brain Imaging
- Added indications for Magnetic Resonance Imaging (MRI) and amyloid beta positron emission tomography (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
- Ultrasound or arthrocentesis as preliminary tests were placed only in the “septic arthritis” indication
Vascular Imaging
- Computed tomography angiography (CTA) and magnetic resonance angiography (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 peripheral artery disease: Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with American College of Radiology Appropriateness Criteria
- Suboptimal imaging option downgrades/removals in Brain, Head and Neck and Abdomen/Pelvis
Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Cardiology Clinical Appropriateness
Updates by section
Imaging of the Heart
- Resting Transthoracic Echocardiography (TTE)
- Expanded frequency of echocardiographic evaluation in patients on mavacamten for treatment of hypertrophic obstructive cardiomyopathy
- Expanded criteria for echocardiographic evaluation to allow a single screening for cardiac disease in patients undergoing evaluation for solid organ or hematopoietic cell transplant
Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Genetic Testing Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by section
Chromosomal Microarray Analysis
- Clarified recommendations for Genetic Counseling
- Clarified requirements for postnatal evaluation of individuals with:
- Congenital or early onset epilepsy (before age 3 years) without suspected environmental causes
- Autism spectrum disorder, developmental delay, or intellectual disability with no identifiable cause (idiopathic)
- Clarified prenatal evaluation of a fetus with a structural fetal anomaly noted on ultrasound
Pharmacogenomic Testing
- Added Apolipoprotein E (APOE) testing
Polygenic Risk Scores renamed Predictive and Prognostic Polygenic Testing
- Broadened guideline scope to include polygenic expression prognostic testing and multivariable prognostic genetic testing (essentially clarifications)
- Moved these tests to exclusions as they are considered not medically necessary
- Retitled guideline to Predictive and Prognostic Polygenic Testing to address the change in scope
Somatic Testing of Solid Tumors
- Clarified gene expression profiling is to guide adjuvant therapy for localized Breast Cancer
Whole Exome and Whole Genome Sequencing
- Expanded whole exome sequencing (WES) criteria to include congenital or early onset epilepsy (before age 3) without suspected environmental etiology and added other clarifications
- Clarified well-delineated genetic syndrome in criterion for multiple anomalies
- Clarified Genetic Counseling details for WES
Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Radiation Oncology Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by section
Radiation Therapy (excludes Proton)
- Removed criteria for hyperthermia
- Clarified inclusion criteria of the RTOG 1112 protocol
Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Sleep Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by section
Sleep Disorder Management
- Expanded definitions and terminology
- Expanded documentation of hypoventilation
- Expanded criteria for home and in-lab sleep studies
- Added contraindication to automatic positive airway pressure titration for use of supplemental oxygen
- Removed home sleep apnea testing as an option in medical necessity of multiple sleep latency test/maintenance of wakefulness test for suspected narcolepsy
- Management of obstructive sleep apnea (OSA) using Implanted Hypoglossal Nerve Stimulators (HNS):
- Narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by Food and Drug Administration (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
For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines.
Effective October 8, 2024
Surgical Treatment of Femoral Acetabular Impingement, 7.01.592 PBC | Premera HMO
New policy
- Surgical treatment of femoral acetabular impingement is considered medically necessary when criteria are met
Effective August 2, 2024
C3 and C5 Complement Inhibitors, 5.01.571 PBC | Premera HMO
Medical necessity criteria updated
- Confirmed granulocyte clone size updated to ≥ 15% for Soliris (eculizumab), Ultomiris (ravulizumab-cwvz), and Empaveli (pegcetacoplan) for the treatment of paroxysmal nocturnal hemoglobinuria (PNH)
Evaluation of Biomarkers for Alzheimer Disease, 2.04.521 PBC | Premera HMO
Investigational criteria added
- Measurement of biochemical markers of Alzheimer’s disease is considered investigational