Effective August 16, 2020
Updates to AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Chest Imaging
Updates by section:
Tumor or Neoplasm
- Allowed follow up of nodules less than 6 mm in size seen on incomplete thoracic CT, in alignment with follow up recommendations for nodules of the same size seen on complete thoracic CT
- Added new criteria for which follow up is indicated for mediastinal and hilar lymphadenopathy
- Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry
Parenchymal Lung Disease – not otherwise specified
- Removed as it is covered elsewhere in the document (parenchymal disease in “Occupational lung diseases” and pleural disease in “Other thoracic mass lesions”)
Interstitial lung disease (ILD), non-occupational, including idiopathic pulmonary fibrosis (IPF)
- Defined criteria warranting advanced imaging for both diagnosis and management
Occupational lung disease (Adult only)
- Moved parenchymal component of asbestosis into this indication
- Limited evaluation of clinically suspected rupture to patients with silicone implants
Chest Wall and Diaphragmatic Conditions
- Removed screening indication for implant rupture due to lack of evidence indicating that outcomes are improved
- Added Berylliosis
Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Oncology Imaging
Updates by section:
MRI breast
- New indication for BIA-ALCL
- New indication for pathologic nipple discharge
- Further define the population of patients most likely to benefit from preoperative MRI
Breast cancer screening
- Added new high risk genetic mutations appropriate for annual breast MRI screening
Lung cancer screening
- Added asbestos-related lung disease as a risk factor
Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Sleep Disorder Management
Updates by section:
Bi-Level Positive Airway Pressure Devices
- Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and aligns with Medicare requirements for use of BPAP
Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing
Effective August 7, 2020
IL-5 Inhibitors, 5.01.559
Cinqair® (reslizumab) has been added to the policy and may be considered medically necessary as an add-on maintenance treatment for patients ages 18 and older with severe asthma when criteria are met. The following re-authorization criteria have been added to the policy: a decrease in requirement for oral steroids, exacerbation frequency, ER and urgent care visits, and hospitalizations; or a decrease in the frequency and severity of asthma symptoms; or an increase in quality of life measures and ability to perform activities of daily living.
Effective July 2, 2020
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569
Site of service criteria and reference to policy, Site of Service: Select Surgery Procedures – 11.01.524, have been removed. Site of service will be included in the medical necessity review for the primary procedure (knee arthroplasty, knee arthroscopy) using InterQual® criteria.
Electrostimulation and Electromagnetic Therapy for Treating Wounds, 2.01.57
This policy was previously archived in 2018 and is being reinstated. Electrical stimulation and electromagnetic therapy for the treatment of wounds is considered investigational.
Erythroid Maturation Agents, 5.01.614
Reblozyl® (luspatercept-aamt) has been added to the policy and may be considered medically necessary for the treatment of anemia in adults ages 18 and older with beta thalassemia when criteria are met.
Meniscal Allografts and Other Meniscal Implants, 7.01.15
Site of service criteria and reference to policy, Site of Service: Select Surgery Procedures – 11.01.524, have been removed. Site of service will be included within the medical necessity review for a knee arthroscopy procedure using InterQual® criteria.
Miscellaneous Oncology Drugs, 5.01.540
Padcev™ (enfortumab vedotin-ejfv) has been added to the policy and may be considered medically necessary for the treatment of locally advanced or metastatic urothelial cancer (mUC) in adults ages 18 and older when criteria are met.
Effective June 5, 2020
Miscellaneous Oncology Drugs, 5.01.540
Darzalex® (daratumumab) has been added to the policy and may be considered medically necessary for the treatment of multiple myeloma in adults when used as a combination treatment or monotherapy when criteria are met.
Effective May 17, 2020
Effective for dates of service on and after May 17, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Vascular Imaging
Updates by section:
Aneurysm of the abdominal aorta or iliac arteries
- Added new indication for asymptomatic enlargement by imaging
- Clarified surveillance intervals for stable aneurysms as follows:
- Treated with endografts, annually
- Treated with open surgical repair, every 5 years
Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
- Added surveillance indication and interval for surgical bypass grafts