Effective September 11, 2022
Updates to
AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM
Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging
Updates by section
Extremity Imaging
Fracture
- Added indication for evaluation of supracondylar fracture
- Added CT as an alternative to MRI for tibial plateau fracture
General information/overview
- Allowed exception to specified durations of conservative management in rare cases
Perioperative imaging (including delayed hardware
failure), not otherwise specified
- Added statement that advanced imaging is not indicated for robotic-assisted hip arthroplasty
Rotator cuff tear
- Updated conservative management time from 4 weeks to 6 weeks for rotator cuff tear
Shoulder arthroplasty
- Added statement that advanced imaging is not indicated for robotic-assisted shoulder arthroplasty
Spine Imaging
Cervical injury
- Clarified that post-traumatic neurologic deficit refers specifically to an exam finding
General information/overview
- Allowed exception to specified durations of conservative management in rare cases
Perioperative and periprocedural imaging
- Added requirement for initial evaluation with radiographs
Thoracic or lumbar injury
- Clarified that neurologic deficit refers specifically to an exam finding
Vascular Imaging: Brain, Head and Neck
Pulsatile tinnitus
- Added optional CTA/MRA neck evaluation for pulsatile tinnitus
Stenosis or occlusion, extracranial carotid arteries
- Added new screening indications for post-neck irradiation and incidental carotid calcification
- Revised surveillance guidelines to align with Society for Vascular Surgery for annual imaging, post-revascularization after first year
Stroke or transient ischemic attach (TIA)
- Divided this section into two categories: intracranial evaluation and extracranial evaluation
- Revised guidelines to align with American Hospital Association/American Society of Anesthesiologists
- Allowed CTA/MRA of the neck without previous prerequisite for subacute stroke/TIA
- Allowed CTA/MRA for chronic posterior circulation stroke/TIA
- Added indication for carotid ultrasound
Vascular Imaging: Abdomen and Pelvis
Acute aortic syndrome
- Added optional pelvic imaging
Aneurysm of the abdominal aorta or iliac arteries
- Screening: Added femoral aneurysm to the list of lower extremity sites
- Management: Revised guidelines to align with Society for Vascular Surgery for post-endovascular repair to repeat imaging 12 months after baseline
- Surveillance: Revised guidelines to align with Society for Vascular Surgery for stable aneurysms treated with endographs
- Duplex arterial ultrasound annually
- CT every 5 years
Venous thrombosis or occlusion
- Added optional pelvic imaging to Imaging Study section
Vascular Imaging: Upper Extremity
Peripheral arterial disease (PAD)
- Added any sign or symptom with inconclusive physiologic testing, including exercise testing, to diagnostic criteria for suspected PAD and management of known PAD
- Added criteria for the management of PAD: resting ischemic pain to unilateral cold painful hand
Vascular Imaging: Lower Extremity
Peripheral arterial disease (PAD)
- Added any sign or symptom with inconclusive physiologic testing, including exercise testing, to diagnostic criteria for suspected PAD
- Revised guidelines to align with Society for Vascular Surgery by adding indication for ultrasound surveillance for repaired popliteal artery aneurysm
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM
Specialty Health® Clinical Appropriateness Guidelines for Sleep Disorder
Management.
Updates by section
Sleep Disorder Diagnostic Management
Established sleep disorder (OSA or other) - follow-up
laboratory studies
- Added option that a follow-up, in-lab sleep study may be allowed to adjust device settings after insertion of a hypoglossal nerve stimulator
Multiple sleep latency testing (MSLT) and/or maintenance
of wakefulness testing (MWT)
- Added MWT indication for occupational safety
Sleep Disorder Treatment Management
Management of obstructive sleep apnea using oral
appliances
- Added age indication for patients age 16 years and older to the use of a custom fabricated oral appliance
Effective September 4, 2022
Updates to
AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after September 4, 2022, the following updates will apply to the AIM
Specialty Health® Clinical Appropriateness Guidelines for Genetic Testing
Updates by section
Hereditary Cardiac Disease
Appropriate use criteria
- Added general genetic testing criteria
Genetic testing of affected individuals
- Moved content with specific cardiac conditions in "Testing of Asymptomatic Individuals" to this section
Genetic testing in the evaluation of sudden cardiac
arrest
- Added this new section and medical necessity criteria
Post-mortem genetic testing
- Added new medical necessity criteria
Reproductive Carrier Screening and Prenatal Diagnosis
Preimplantation genetic testing of embryos
- Added polygenetic risk scores (PRS) to the list of not medically necessary conditions
Single Gene and Multifactoral Conditions
Thrombophilia testing
- Removed the criterion for an individual with unprovoked venous thromboembolism
Somatic and Hematologic Tumors Genetic Testing
Conditions for which testing may be medically necessary
- Added FoundationOne® as medically necessary for non-small cell lung cancer (NSCLC) stage IIIB and above
- Added targeted multigene panels as medically necessary for endometrial cancer
Cell-free testing
Listed ctDx Lung™ and Target Selector™ NGS Lung Panel as the only approved targeted multi-gene panels for biomarkers in locally advanced or metastatic non-small cell lung cancer (NSCLC)
Cancer screening
- Added timing of PSA testing in relation to the PCA3 or ConfirmMDx test
- Moved criteria for gene expression classifier testing for indeterminate thyroid nodules (ITN) from Table 1 to this section
Effective September 2, 2022
Cervical
Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560
Anterior cervical fusion
Indications added
- Spine fracture and/or dislocation
- Cervical spine revision surgery
Medical necessity
criteria updated
Indication: Cervical pseudoarthritis
- Cervical pseudarthrosis must be symptomatic
- Imaging shows evidence of hardware failure
- Pain aligns with the level of pseudoarthritis
- A cervical spine MRI or CT scan 12 months after a previous spinal fusion shows non-union at the same level as symptom/exam findings
Posterior cervical fusion
Indication added
- Implant/instrumentation failure
Medical necessity
criteria updated
Indication: Cervical pseudoarthritis
- Imaging shows evidence of hardware failure
- Pain aligns with the level of pseudoarthritis
- A cervical spine MRI or CT scan 12 months after a previous spinal fusion shows non-union at the same level as symptom/exam findings
Hysterectomy
for Non-Malignant Conditions, 7.01.548
Medical necessity criteria updated
Criteria for uterine fibroids has been separated from the abnormal uterine bleeding indication
Indications added
- Chronic pelvic inflammatory disease (PID)
- Pelvic pain
Lumbar
Spinal Fusion in Adults, 7.01.542
Indication added
Revision surgery for implant/instrumentation failure
Spravato®
(esketamine) Nasal Spray, 5.01.609
All Indications
Medical necessity criteria updated
- Documentation of depression must include the patient's symptoms and their severity as measured by one or more standardized depression rating scales
- The patient must have no current use of any mind- or mood-altering substances, including but not limited to alcohol, marijuana, stimulants, and hallucinogens/psychedelics
All Indications
Medical necessity criteria added
A new course of Spravato® treatment when the patient was previously treated with this drug
All Indications
Re-authorization criteria updated
- The patient must not have a current substance use disorder, unless there has been complete abstinence for a month
- The patient must have no current use of any mind- or mood-altering substances, including but not limited to alcohol, marijuana, stimulants, and hallucinogens/psychedelics
Upper
Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533
Medical necessity criteria updated
- The timing of persistent GERD symptoms following treatment with daily proton pump inhibitor (PPI) therapy has been changed from 4 - 8 weeks to 8 weeks
- Criterion added that UGI may be performed to evaluate returning GERD or heartburn symptoms after the completion of proton pump inhibitor (PPI) treatment
- Deleted criterion that a UGI may be performed after 6-12 weeks of treatment with a histamine H2-receptor antagonist
- Follow-up of known eosinophilic esophagitis has been added to the list of medically necessary conditions
Wearable
Cardioverter-Defibrillators as a Bridge to Implantable
Cardioverter-Defibrillator Placement, 2.02.506
Medical necessity criteria updated
A 90-day time limit has been added for the use of a wearable cardioverter-defibrillator as a bridge to a permanent implantable (internal) cardioverter-defibrillator surgery
Effective August 5, 2022
Drugs for
Rare Diseases, 5.01.576
Pompe Disease
Site of service review added
- Nexviazyme™ (avalglucosidase alfa-ngpt) IV
Thyroid Eye Disease (TED)
Medical necessity criteria updated
- Tepezza™ (teprotumumab-trbw)
- The patient must have tried glucocorticoids before this drug can be prescribed
- This drug will be given within 9 months of completing the glucocorticoid trial
- This drug must be prescribed by an ophthalmologist with expertise in TED treatment or endocrinologist with expertise in TED treatment
- This drug is not being used in combination with another biologic drug that can be used to treat TED
Site of
Service: Infusion Drugs and Biologic Agents, 11.01.523
Site of service review added
- Nexviazyme™ (avalglucosidase alfa-ngpt) IV
Effective July 7, 2022
Immune Checkpoint Inhibitors, 5.01.591
Site of service review added
- Keytruda® (pembrolizumab)
- Opdivo® (nivolumab)
Site of
Service: Infusion Drugs and Biologic Agents, 11.01.523
Site of service review added
- Keytruda® (pembrolizumab)
- Opdivo® (nivolumab)
Effective July 1, 2022
For dates of service on or after July 1, 2022, Premera will no longer review home sleep studies for prior authorization and medical necessity. Providers will no longer need to submit a request through AIM Specialty Health® for these services. AIM Specialty
Health® will still review supplies/equipment and in lab sleep studies.
Effective June 3, 2022
Phosphoinositide
3-kinase (PI3K) Inhibitors, 5.01.592
Indication removed
- Aliqopa® (copanlisib)
- Treatment of chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) with this drug is not FDA-approved or supported by the National Comprehensive Cancer Network (NCCN)