Effective January 1, 2020
Pilot Policy for Designated Centers of Excellence: Total Knee or Total Hip Replacement, 7.01.568
Total knee or total hip replacement (arthroplasty) for the treatment of osteoarthritis may be considered medically necessary when criteria are met and the surgery is performed in a Designated Center of Excellence. This policy only applies to members whose plan includes the Total Joint Replacement Centers of Excellence Program.
Effective November 10, 2019
Updates to AIM Specialty Health® Clinical Appropriate Guidelines
Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Specialty Health® Advanced Imaging Clinical Appropriateness Guidelines.
Cardiac Imagining Guideline contains updates to the following:
Post-cardiac transplantation evaluation when any of the following applies: evaluation of new or worsening cardiac signs, symptoms or new EKG abnormalities; or, surveillance of a stable patient (no new or worsening cardiac signs or symptoms) within the first 6 months of transplant; or, surveillance of a stable patient (no new or worsening cardiac signs or symptoms) at 3-month intervals at 6 to 24 months post-transplant; or, annual surveillance of a stable patient (no new or worsening cardiac signs or symptoms) more than 24 months post-transplant.
Head and Neck Imagining Guideline contains updates to the following:
Sinusitis/rhinosinusitis (adult and pediatric): Defined a minimal treatment requirement for uncomplicated sinusitis prior to imaging. Defined indications for preoperative planning for image navigation following a clinical policy statement on appropriate use from the AAO-HNS. Removed CT screening for immunocompromised patients based on lack of evidence. Aligned pediatric and adult sinusitis guidelines and pediatric sinusitis guidelines with ACR and AAO-HNS.
Trauma (adult and pediatric): Radiograph requirement added for suspected mandibular trauma. MRI TMJ in trauma for suspected internal derangement in surgical candidates.
Neck mass: Align adult neck imaging guideline with a high-quality guideline from the American Academy of Otorhinolaryngology – Head and Neck Surgery (AAO-HNS) including mass size and feature requirements for advanced imaging.
Parathyroid adenoma (adult and pediatric): Further defined the patient population that needs evaluation for parathyroid adenomas. Position CT as a diagnostic test after both ultrasound and parathyroid scintigraphy. Remove MRI as a modality to evaluate for parathyroid adenomas based on lack of evidence for diagnostic accuracy.
Temporomandibular joint dysfunction (adult and pediatric): Added requirement for conservative treatment and planned intervention for suspected osteoarthritis.
Hearing loss: More clearly delineated appropriate modalities based on types of hearing loss in pediatric patients.
Oncologic Imagining Guideline contains updates to the following:
Colorectal cancer: Removal of FDG-PET/CT for radiation planning to align AIM Appropriateness Criteria with NCCN: ACR appropriateness level 6 (may be appropriate) only for detection of distant metastases. Not addressed for locoregional staging; Low level evidence to support use of PET-CT imaging for radiation treatment planning; and NCCN states that PET-CT is not indicated for pre-operative staging of rectal cancer. PET-CT can also be considered for potentially curable M1.
Germ cell tumors – testis and ovary: Align AIM Appropriateness Criteria with NCCN for PET-CT, evidence for PET-CT imaging to evaluate residual mass < 3 cm applies to seminoma ONLY. Removed this indication for nonseminoma and malignant ovarian germ cell cancer. Residual nonseminomatous germ cell tumors > 1 cm require surgery.
Hepatobiliary cancer: Align AIM Appropriateness Criteria with NCCN for management, screening and surveillance.
Kidney cancer: Align AIM Appropriateness Criteria with NCCN Kidney Cancer Guidelines and ACR Appropriateness Criteria for use of PET imaging in staging and management of Kidney Cancer/Renal Cell Carcinoma. ACR appropriateness level 3 (usually not appropriate) for use of PET imaging in staging of kidney cancer. NCCN states the value of PET in RCC remains to be determined.
Lung cancer – non-small cell: Use of MRI limited to scenarios where additional imaging would impact management.
Lymphoma – Non-Hodgkin: The majority of mucosal melanomas originate from the head and neck. The qualifier added is intended to prevent inappropriate use of MRI head and neck when of other origin besides head and neck.
Prostate cancer: Additional criteria for management to address active surveillance in reaction to NCCN recommending an annual limit on mpMRI for active surveillance.
Suspected metastases not otherwise specified: New criteria for Sodium Fluoride PET.
Vascular Imagining Guideline contains updates to the following:
General vascular: Added diagnostic testing strategy for TAVI/TAVR carotid evaluation with initial ultrasound.
Aneurysm – intracranial: Further define neurological signs and symptoms suggestive of intracranial aneurysm.
Carotid stenosis or occlusion: Advanced imaging as an add on test for problem solving when ultrasound suggests a high-grade stenosis.
Hemorrhage – intracranial or subarachnoid: Define use of vascular imaging as an add on test in patients following intracranial hemorrhage. Sequential diagnostic testing strategy for non-acute stroke or TIA with CTA or MRA as an add on test to change management in select circumstances for unexplained strokes.
Venous thrombosis or compression – extracranial: Added requirement for nondiagnostic venous ultrasound. Further define isolated headache pattern that may require imaging to exclude venous sinus thrombosis. Adopt a sequential diagnostic testing strategy starting with CT or MRI for low risk groups (no risk factors and negative D-dimer).
Aortic aneurysm or dissection: Annual evaluation of stable aneurysms (new for advanced imaging, aligns with echocardiography guidelines). New screening indication for high risk adults, annual screening for pediatrics.
Other vascular indications: New criteria for PAH incorporating a diagnostic testing strategy. Annual evaluation of stable aneurysms (new for advanced vascular imaging) 6-month evaluation of newly diagnosed aneurysms. Further define diagnostic indications for suspected aneurysm for advanced imaging. Align pediatrics with adult guidelines. Added requirement that intra-abdominal bleeding be unexplained for advanced vascular imaging. Remove generalized atherosclerotic disease and follow up based solely on abnormal imaging, requirement for 4 or more antihypertensive medications. More specific clinical indications for CTA/MRA in the diagnosis of suspected stenosis. Duplex ultrasound guideline with CTA/MRA alignment in diagnosis, management, and surveillance for upper extremity. Ultrasound requirement for suspected DVT prior to advanced vascular imaging. Remove Raynaud’s syndrome based on low diagnostic yield and low diagnostic accuracy. Remove CTA/MRA for with ABI less than 0.9 alone for peripheral arterial disease.
Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines: Radiation Oncology.
Proton Beam Therapy Guideline contains updates to the following:
Revised proton beam therapy considerations and indications for sinonasal cancer, melanoma of the uveal tract, and pediatric tumors.
Effective August 2, 2019
Pharmacologic Treatment of Osteoporosis, 5.01.596
Forteo® (teriparatide), Tymlos® (abaloparatide), and Prolia® (denosumab) may be considered medically necessary when criteria are met. They are considered investigational when criteria are not met. The policy is revised to add medical necessity criteria for Evenity™ (romosozumab-aqqg) and update the criteria for Tymlos® (abaloparatide).
Synthetic Cartilage Implants for Joint Pain, 7.01.160
Synthetic cartilage implants are considered investigational for the treatment of articular cartilage damage.