Effective May 2, 2023
Applied Behavioral Analysis (ABA), 3.01.510 PBC | Premera HMO
Note added
Applied behavioral analysis (ABA) may be considered medically necessary when criteria for Diagnosis, Initial Functional Behavioral Analysis, Initial Treatment Plan, ABA Treatment Services, ABA Treatment Services Settings, Continued Treatment are met. Some plans may not review all of the criteria listed in policy.
Psychotherapy sessions
Section removed
DiagnosisSection added
Medical necessity criteria updated
- Updated diagnostic terminology for consistency with the DSM-5/DSM-5-TR
- Expanded the types of clinicians who can diagnose Autism Spectrum Disorder
Initial Functional Behavioral Analysis
Section added
Initial treatment plan
Section added
ABA treatment services
Section added
Medical necessity criteria updated
Clarified that the maximum number of medically necessary hours of daily and weekly ABA services applies only treatment hours (not to other components of ABA)
ABA treatment settings
Section added
Medical necessity criteria updated
Updated the requirements for agencies to be considered to be ABA treatment services providers
Continued treatment
Section added
Medical necessity criteria updated
Clarified that the after the initial Functional Behavioral Analysis, Functional Behavioral Analysis re-assessments are considered to be medically necessary no more frequently than once every 6 months
Applied Behavior Analysis (ABA) service providers
Section updated
- Expanded the types of clinicians who may provide direct treatment services
- Clarified which ABA services can and cannot be provided by master’s and doctoral level clinicians who are not licensed to practice independently and can only practice under supervision
Benefit application
Section updated
- Added a provision in the Benefit Application section that assessments and supporting assessments by behavioral technicians/therapy assistants/paraprofessionals are non-covered (excluded) services except when included in their legally permitted scope of licensure
- Removed the restriction for group treatment sessions that only social skills group sessions are covered for ABA
- Removed the limitation of a maximum of two group sessions daily
- Added “Group treatment sessions are covered for only one clinician for an identified individual regardless of how many clinicians were present for a group session”
- Added general parenting coaching, and training of nannies or au-pairs or similar persons, to the list of activities that are not considered to constitute ABA services
Effective April 9, 2023
Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
(formerly AIM Specialty Health®)
Effective for dates of service on and after April 9, 2023, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines for Advanced Imaging
Updates by section
Abdominal and pelvic imaging
Abdominal/pelvic pain, undifferentiated
Removed indication for MRI following nondiagnostic CT
Uterine leiomyomata
Added indication for advanced imaging when ultrasound suggests leiomyosarcoma
Pancreatic indications
Added indication for pancreatic duct dilatation
Pancreatic mass
Added allowance for more frequent follow-up of lesions with suspicious features or in high-risk patients
Pancreatitis
Removed allowance for MRI following nondiagnostic CT
Pelvic floor disorders
Added indication for MRI pelvis in chronic constipation when preliminary testing is nondiagnostic
Brain imaging
Bell’s palsy
Limited the use of CT to scenarios where MRI cannot be performed
Meningioma
Added more frequent surveillance for WHO grade II/III
Seizure disorder
Added indication for advanced imaging in pediatric patients with nondiagnostic EEG
Chest imaging
Imaging abnormalitiesAdded indication for evaluation of suspected tracheal or bronchial pathology
Perioperative imaging
Added indication for imaging prior to lung volume reduction procedures
Head and neck imaging
Perioperative imaging
Added indication for imaging prior to facial feminization surgery
Oncologic imaging
Criteria aligned with National Comprehensive Cancer Network (NCCN) for the following:
- Breast cancer screening
- Cervical
- Head and neck
- Histiocytic neoplasms
- Lymphoma (non-Hodgkin and leukemia)
- Multiple myeloma
- Thoracic
- Thyroid
Prostate cancer
- Updated respective conventional imaging prerequisites for 18F Fluciclovine/11C PET/CT and 68Ga PSMA/18F-DCFPyL PET/CT, based on utility of conventional imaging at various PSA thresholds and removal of low risk disease waiver from conventional imaging footnote
- Added 68Ga PSMA or 18F-DCFPyL PET/CT indication aligned with FDA-approved use of Pluvicto (radioligand) treatment for metastatic castrate-resistant disease
Effective for dates of service on and after April 9, 2023, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines for Advanced Imaging of the Heart (formerly AIM Specialty Health®)
Updates by section
Cardiac Imaging
CT coronary angiography (CCTA)
Indications added
- Abnormal prior testing
- Expanded use for evaluation of CAD (now a first-line modality)
- Preoperative testing
Indication removed
Suspected anomalous coronary arteries (basis for suspicion required)
Fractional Flow Reserve from CCTA (FFR-CT)
Indication updated
Symptomatic person with 40 - 90% coronary stenosis who has failed guideline directed medical therapy and has undergone a CCTA within the previous 90 days
Resting cardiac MRI
Indication added
Fabry disease
Indications updated
- Arrhythmogenic right ventricular dysplasia (ARVD) requirements
- Suspected anomalous coronary arteries (basis for suspicion required)
- Suspected myocarditis (basis for suspicion required)
Resting transthoracic echocardiography (TTE)
Valvular heart disease
Criteria updated
- Removed requirement of valvular dysfunction for those who had surgical mitral valve repair
- Updated frequency of surveillance in patients with prosthetic valves and those who had transcatheter valve replacement/repair
- Removed moderate/severe mitral regurgitation for those who had transcatheter mitral valve repair
Stress cardiac MRI
Indications added
- Abnormal prior testing
- Expanded use for evaluation of CAD (now a first-line modality)
- Preoperative testing
Stress testing with imaging
Indications removed
- Suspected CAD without symptoms
- Established CAD with symptoms
- Established CAD without symptoms
Criteria updated
- Modified indications for suspected CAD with symptoms
- Determined need for testing by pretest probability
- Expanded definition of “chest pain” to include ischemic equivalent pain elsewhere
- Included dyspnea as a standalone symptom
- Treating physician to select imaging modality
- Clarified that exercise is preferred over pharmacologic testing in patients referred for stress testing with imaging
- Clarified that patients with atypical symptoms to undergo non-imaging stress testing (assuming capable of exercise and no precluding resting EKG abnormalities)
Effective for dates of service on and after April 9, 2023, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines for Radiation Oncology (formerly AIM Specialty Health®)
Updates by section
Radiation Therapy
Gastrointestinal (GI) cancers
Removed plan comparison requirement for cholangiocarcinoma, esophageal, gastric, hepatocellular, and pancreatic cancer, because IMRT has become standard of care for curative treatment of these cancers
Oligometastatic extracranial disease
Added indication for adrenal metastases in SABR-COMET clinical trial
Prostate cancer - brachytherapy
Added indication for high-dose rate monotherapy in low- and intermediate-risk disease
Image-guided radiation therapy (IGRT)
- Added surface-based guidance technique (no change in coding)
- Added statement that IGRT is not medically necessary to guide superficial radiotherapy for non-melanoma skin cancer (supported by American Society for Radiation Oncology clinical practice guideline)
Therapeutic Radiopharmaceuticals
Prostate cancer
Added indication for Lutetium Lu 177 vipivotide tetraxetan (Pluvicto™), FDA approved for the treatment of adult patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer who have been treated with AR pathway inhibition and taxane-based chemotherapy
Effective March 1, 2023
Drugs for Rare Diseases, 5.01.576 PBC | Premera HMO
Medical necessity criteria updated
Lumizyme® (alglucosidase alfa)
- Added dose limit of no more than 20 mg per kg of body weight administered every 2 weeks
Site of service review added
- Mepsevii® (vestronidase alfa-vjbk)
- Naglazyme® (galsulfase)
Drug added
Mepsevii® (vestronidase alfa-vjbk)
- Treatment of mucopolysaccharidosis type VII (MPS VII; Sly syndrome)
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523 PBC | Premera HMO
Drugs added
- Mepsevii® (vestronidase alfa-vjbk)
- Naglazyme® (galsulfase)