Effective March 13, 2022
Updates to AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging.
Updates by section
Brain imaging
Acoustic neuroma
- Removed indication for CT brain and replaced with CT temporal bone
Meningioma
- Added new guideline for follow-up intervals
Pituitary adenoma
- Removed allowance for CT following nondiagnostic MRI in macroadenoma
Tumor, not otherwise specified
- Added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features
Chest imaging
Pneumonia
- Removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing
Pulmonary nodule
- Revised criteria for follow-up of nodules detected on lung cancer screening CT based on Lung-RADS
Head and neck imaging
Parathyroid adenoma
- Added situations where surgery is recommended based on American Association of Endocrine Surgeons guidelines
Temporomandibular joint dysfunction
- Added duration of required conservative management
Abdominal and pelvic imaging
Azotemia
Hematuria
- Revised criteria for asymptomatic microhematuria based on American Urological Association guideline
Intussusception
Jaundice
- Added requirement for ultrasound prior to advanced imaging in pediatric patients
Sacroiliitis
- Added situations where advanced imaging is indicated (predisposing condition or equivocal radiographs)
Uterine leiomyomata (fibroids)
- Added requirement for ultrasound prior to MRI
- Expanded indication to include most other fertility-sparing procedures
Oncologic imaging
- Updated recommendations based on the National Comprehensive Cancer Network (NCCN) for the following:
- Breast cancer
- Hodgkin lymphoma
- Non-Hodgkin lymphoma
- Melanoma
- Neuroendocrine tumors
- Soft tissue sarcoma
- Testicular cancer
- Thyroid cancer
Breast cancer
- Updated clinical scenarios in chart for diagnostic breast MRI and PET/CT for management
Cancer screening
- Added indication for hepatocellular carcinoma screening
- Added age criteria for pancreatic cancer
Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart
Updates by section
Cardiac imaging
Coronary CT Angiography
- Removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk
Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology
- Removed Eastern Cooperative Oncology Group (ECOG) status as definition for performance status throughout guidelines
Effective February 4, 2022
Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia, 7.01.167
New policy
- Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) is considered investigational for all indications, including but not limited to the screening and surveillance of Barrett esophagus and esophageal dysplasia
Drugs for Rare Diseases, 5.01.576
Site of service review added
- Adakveo® (crizanlizumab-tmca)
- Aldurazyme® (laronidase)
- Kanuma® (sebelipase alfa)
Hereditary Angioedema, 5.01.587
Site of service review added
IL-5 Inhibitors, 5.01.559
Site of service review added
Medical necessity criteria updated
- Nucala® (mepolizumab)
Indication: Treatment of adults with eosinophilic granulomatosis with polyangiitis (EGPA)
- Requirement added that patient has been taking prednisone or prednisolone
Indication: Treatment of adults and children age 12 years and older with hypereosinophilic syndrome (HES)
- Genetic testing is required to confirm that the patient does not have FIP1L1-PDGFRA kinase-positive HES
- Requirement has been added that the patient has been taking background HES therapy prior to treatment with this drug
Immune Globulin Therapy, 8.01.503
Site of service review added
- Asceniv™ (immune globulin intravenous, human - slra)
Intravitreal Corticosteroids, 5.01.619
New policy
Drugs added
- Iluvien® (fluocinolone acetonide intravitreal implant)
- Treatment of diabetic macular edema (DME) in patients age 18 years and older
- Ozurdex® (dexamethasone intravitreal implant)
- Treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) in patients age 18 years and older
- Treatment of non-infectious uveitis of the posterior segment of the eye in patients age 18 years and older
- Treatment of diabetic macular edema (DME) in patients age 18 years and older
- Retisert® (fluocinolone acetonide intravitreal implant)
- Treatment of chronic non-infectious uveitis affecting the posterior segment of the eye in patients age 12 years and older
- Yutiq® (fluocinolone acetonide intravitreal implant)
- Treatment of chronic non-infectious uveitis of the posterior segment of the eye in patients age 18 years and older
Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570
Site of service review added
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Site of service review added
- Stelara® (ustekinumab) IV
- Stelara® (ustekinumab) SC
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
Site of service review added
- Uplizna™ (inebilizumab-cdon)
Pharmacotherapy of Arthropathies, 5.01.550
Site of service review added
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18
Policy statement added
- The use of lymphedema pumps applied to the head and neck to treat lymphedema has been added to the list of investigational conditions
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
New drugs added
- Adakveo® (crizanlizumab-tmca)
- Aldurazyme® (laronidase)
- Amondys 45™ (casimersen)
- Asceniv™ (immune globulin intravenous, human – slra)
- Cinqair® (reslizumab)
- Cinryze® (C1 esterase inhibitor [human])
- Kanuma® (sebelipase alfa)
- Stelara® (ustekinumab) IV
- Stelara® (ustekinumab) SC
- Uplizna® (inebilizumab-cdon)
Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11
Medical necessity criteria updated
- For implantable ventricular assist devices (VADs) for end-stage heart failure, criteria updated based on the 2020 MOMENTUM 3 clinical trial
- Criterion added of cardiac index while patient is not on inotropes
- Heart transplant ineligibility criteria removed
Xolair® (omalizumab), 5.01.513
Medical necessity criteria updated
- Indication: Treatment of moderate to severe asthma in adults and children age 6 years and older
- Requirement added that an adult patient is not a smoker, or is enrolled in a smoking cessation program
- Requirement added that the patient weighs between 44 and 330 pounds
- Indication: Treatment of severe chronic idiopathic urticaria in adults and adolescents age 12 years and older
- The requirement of failure to respond to two therapeutic regimens has been reduced to one
- Indication: Treatment of adult patients with inadequately controlled nasal polys
- Requirement added for a pre-treatment IgE antibody score greater than or equal to 30 IU/mL
- Requirement added that the patient weighs between 66 and 330 pounds