Effective March 14, 2021
Updates to AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging
Updates by section:
Brain Imaging
Ataxia, congenital or hereditary
- Combined with congenital cerebral anomalies to create one section
Acoustic neuroma
- More frequent imaging for a watch and wait or incomplete resection
- New indication for Neurofibromatosis type 2 (NF 2)
- More frequent imaging when MRI shows findings suspicious for recurrence
- Single post-operative MRI following gross total resection
- Included pediatrics with known acoustics (rare but NF 2)
Tumor – not otherwise specified
- Repurposed for surveillance imaging of low grade neoplasms
Seizure disorder and epilepsy
- Limited imaging for the management of established generalized epilepsy
- Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy
Headache
- Removed response to treatment as a primary headache red flag
- Included pregnancy as a red flag risk factor
Mental status change and encephalopathy
- Added requirement for initial clinical and lab evaluation to assess for a more specific cause
Brain Imaging and Head and Neck Imaging
Hearing loss
- Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is nondiagnostic or unable to be performed
- Higher allowed threshold for consecutive frequencies to establish SNHL
- Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance
Tinnitus
- Removed sudden onset symmetric tinnitus as an indication for advanced imaging
Chest Imaging and Head and Neck Imaging
Hoarseness, dysphonia, and vocal cord weakness/paralysis – primary voice complaint
- Required laryngoscopy for the initial evaluation of all patients with primary voice complaint
Head and Neck Imaging
Sinusitis/rhinosinusitis
- Added more flexibility for the method of conservative treatment in chronic sinusitis
- Required conservative management prior to repeat imaging for patients with prior sinus CT
Temporomandibular joint dysfunction
- Removed requirement for radiographs/ultrasound
Cerebrospinal fluid (CSF) leak of the skull base
- Added scenario for management of known leak with change in clinical condition
Oncologic Imaging
General content changes to align with current oncology recommendations
- Removal of indications/parameters not addressed by NCCN
- Average risk inclusion criteria for CT Colonography
- New allowances for MRI Abdomen and/or MRI Pelvis by tumor type, liver metastatic disease
- New indications for Acute Leukemia (CT, PET/CT), Multiple Myeloma (MRI, PET/CT), Ovarian Cancer surveillance (CT), Bone Sarcoma (PET/CT)
- Updated standard imaging pre-requisites prior to PET/CT for Bladder/Renal Pelvis/Ureter, Colorectal, Esophageal/GE Junction, Gastric and Non-Small Cell Lung Cancers
- Additional PET/CT management scenarios for Cervical Cancer, Hodgkin Lymphoma
Cancer screening
- New indication for Pancreatic Cancer screening
Breast cancer
- New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment Breast MRI after breast conserving therapy or unilateral mastectomy
Prostate Cancer
- MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE
Axumin PET/CT
- Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)
Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart
Updates by section:
Evaluation of patients with cardiac arrhythmias
- Updated repeat TTE criteria
- Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia
Evaluation of signs, symptoms, or abnormal testing
- Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature
Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology
Updates by section:
Special Treatment Procedure
- Removed IV requirement for chemotherapy
CNS cancer: IMRT for glioblastomas, other gliomas, brain metastases
- Eliminated the plan comparison requirement based on feedback from reviewers that essentially all cases were able to meet criteria - same change for high-grade and low-grade gliomas
- Added new indication for hippocampal sparing whole brain radiotherapy
Lung cancer: IMRT and SBRT for non-small cell, SBRT for small cell; fractionation for non-small cell
- Eliminated the plan comparison requirement for IMRT to treat stage III non-small cell lung cancer
- Removed “due to a medical contraindication” language
- Added new indication as an alternative to surgical resection when certain conditions apply
- Adjusted fractions of thoracic radiotherapy for non-small cell lung cancer
Proton Beam Therapy
- Added new indication for hepatocellular carcinoma and intrahepatic cholangiocarcinoma
Effective March 3, 2021
Medical Necessity Criteria for Pharmacy Edits, 5.01.605
New policy section
New drug added to policy
- Actimmune® (interferon gamma-1b)
- Reducing the frequency and severity of serious infections associated with Chronic Granulomatous Disease (CGD)
- Delaying time to disease progression in patients with severe, malignant osteopetrosis (SMO)
Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620
New policy
The following brand drugs have been added and may be considered medically necessary when criteria are met:
- Beovu® (brolucizumab-dbll)
- Treatment of neovascular (wet) age-related macular degeneration (AMD)
- Eylea® (aflibercept)
- Treatment of neovascular (wet) age-related macular degeneration (AMD)
- Treatment of macular edema following retinal vein occlusion (RVO)
- Treatment of diabetic macular edema (DME)
- Treatment of diabetic retinopathy (DR)
- Lucentis® (ranibizumab)
- Treatment of neovascular (wet) age-related macular degeneration (AMD)
- Treatment of macular edema following retinal vein occlusion (RVO)
- Treatment of diabetic macular edema (DME)
- Treatment of diabetic retinopathy (DR)
- Treatment of myopic choroidal neovascularization (mCNV)
- Macugen® (pegaptanib)
- Treatment of neovascular (wet) age-related macular degeneration (AMD)
Effective February 5, 2021
The following policies are being reinstated and used to review medical necessity for dates of service starting February 5, 2021 and after:
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.11
Artificial Pancreas Device Systems, 1.01.30
Medical necessity criteria updated
- The age for an artificial pancreas device system has been lowered from age 14 to age 6 and older
- The age for a hybrid closed loop insulin delivery system has been lowered from age 7 to age 6 and older
Cochlear Implant, 7.01.05
Medical necessity criteria updated
- The age for bilateral hearing loss has been lowered from 12 months to 9 months or older
Continuous Passive Motion in the Home Setting, 1.01.10
Coronary Angiography for Known Suspected Coronary Artery Disease, 2.02.507
Deep Brain Stimulation, 7.01.63
Hip Arthroplasty in Adults, 7.01.573
Hospital Beds and Accessories, 1.01.520
Knee Arthroplasty in Adults, 7.01.550
Knee Arthroscopy in Adults, 7.01.549
Medical necessity criteria updated
- Knee arthroscopy for a partial meniscectomy is considered not medically necessary for a degenerative tear(s) that do not result in functional impairment symptoms
Knee Orthoses (Braces), Ankle foot Orthoses and Knee-Ankle-Foot-Orthoses, 1.03.501
Mastectomy for Gynecomastia, 7.01.521
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
Panniculectomy and Excision of Redundant Skin, 7.01.523
Patient Lifts, Seat Lifts, and Standing Devices, 1.01.519
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.26
Power Operated Vehicle (Scooters) (excluding motorized wheelchairs), 1.01.527
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18
Reduction Mammoplasty for Breast-Related Symptoms, 7.01.503
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy, 7.01.143
Rhinoplasty, 7.01.558
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids, 7.01.84
Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546
Transcatheter Aortic Valve Implantation for Aortic Stenosis, 7.01.132
Treatment of Varicose Veins, 7.01.519
Upper GI Endoscopy, 2.01.533
Medical necessity criteria updated
- Routine preoperative UGI is considered not medically necessary for individuals scheduled for bariatric surgery unless they meet the clinical criteria
Vagus Nerve Stimulation, 7.01.20
Wearable Cardioverter Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement , 2.02.506
Wheelchairs (Manual or Motorized), 1.01.501
Effective January 1, 2021
Pharmacotherapy of Arthropathies, 5.01.550
Medical necessity criteria updated
- Actemra® (tocilizumab)
- Treatment of moderate to severe rheumatoid arthritis. Patient must have tried and failed Humira® (adalimumab) or this drug cannot be tolerated
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Site of service review added
Medical necessity criteria updated
- Tysabri® (natalizumab)
- Second-line treatment for Crohn’s disease requires trial and treatment failure with corticosteroids, or azathioprine, 6-mercaptopurine, methotrexate, Cimzia® (certolizumab pegol), Entyvio® (vedolizumab), Humira® (adalimumab), Remicade® (infliximab), or Stelara® (ustekinumab)
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
New drug added to policy
- Ilaris® (canakinumab)
- Treatment of periodic fever syndromes
- Treatment of Still’s disease in patients age 2 and older
Pharmacotherapy of Multiple Sclerosis, 5.01.565
Site of service review added
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
New drug added to policy
Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551
Policy renamed
- From “Granulocyte Colony-Stimulating Factors (G-CSF) Use in Adult Patients” to “Use of Granulocyte Colony-Stimulating Factors (G-CSF)”
Medical necessity criteria updated
- Udenyca® (pegfilgrastim-cbqv) and Ziextenzo® (pegfilgrastim-bmez)
- As a first-line treatment for patients under age 18 who are at risk of severe febrile neutropenia
- As a second-line treatment for patients age 18 or older who are at risk of severe febrile neutropenia when Granix® (tbo-filgrastim) or Nivestym® (filgrastim-aafi) has been tried and failed, or there is a medical reason why those two drugs cannot be taken, or there is a valid medical reason why self-injection or home nursing cannot be performed
- Neulasta® (pegfilgrastim) / Neulasta Onpro®, Fulphila® (pegfilgrastim-jmdb), and Nyvepria™ (pegfilgrastim-apgf)
- As a second-line treatment of patients under age 18 who are at risk of severe febrile neutropenia when Udenyca® (pegfilgrastim-cbqv) or Ziextenzo® (pegfilgrastim-bmez) have been tried and failed, or there is a medical reason why those two drugs cannot be taken
- As a third-line treatment of patients age 18 or older who are at risk of severe febrile neutropenia when Granix® (tbo-filgrastim) or Nivestym® (filgrastim-aafi) has been tried and failed, when Udenyca® (pegfilgrastim-cbqv) or Ziextenzo® (pegfilgrastim-bmez) has been tried and failed, or there is a medical reason why those drugs cannot be taken
Effective December 3, 2020
Hematopoietic Cell Transplantation for Hodgkin Lymphoma, 8.01.29
Criteria updated
- Tandem autologous hematopoietic cell transplantation (HCT) medical necessity criteria have been removed
- Tandem autologous hematopoietic cell transplantation (HCT) is now considered investigational in patients with Hodgkin lymphoma
Miscellaneous Oncology Drugs, 5.01.540
New drugs added to policy
- Blincyto® (blinatumomab)
- Treatment of adults and children for B-cell precursor acute lymphoblastic leukemia (ALL) in first or second complete remission with minimal residual disease (MRD)
- Treatment of adults and children with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL)
- Leukine® (sargramostim)
- Treatment of acute myeloid leukemia after induction chemotherapy
- Mobilization and following transplant of autologous peripheral blood progenitor cells
- Myeloid reconstitution after (allogenic or autologous) bone marrow transplant
- Treatment for bone marrow transplant (allogenic or autologous) failure or engraftment delay
- Treatment for exposure to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome)
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517
New drug added to policy
- Cyramza® (ramucirumab)
- Treatment of advanced or metastatic gastric or gastro-esophageal junction (GEJ) cancer that has continued to grow while on or after prior fluoropyrimidine- or platinum-containing chemotherapy when used as a single agent or with paclitaxel
- Treatment of metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) gene changes (exon 19 or exon 21) as first-line therapy when used with erlotinib
- Treatment of metastatic non-small cell lung cancer (NSCLC) that has continued to grow while on or after platinum-based chemotherapy when used with docetaxel
- Treatment of metastatic colorectal cancer (mCRC) that has continued to grow while on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine when used with a FOLFIRI chemotherapy combination
- Treatment of hepatocellular carcinoma (HCC) in patients who have an elevated alpha fetoprotein and have been treated with sorafenib when used as a single agent