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Dear Provider, This Is a High-Level Summary of the Clinical Appropriateness Guidelines Effective September 12, 2021

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Dear Provider, This Is a High-Level Summary of the Clinical Appropriateness Guidelines Effective September 12, 2021 May 17, 2021 Subject: AIM Specialty Health® Clinical Appropriateness Guidelines Dear Provider, This is a high-level summary of the Clinical Appropriateness Guidelines effective September 12, 2021. You may access the complete guidelines and revision documents on AIM’s website. Joint Surgery • Physical Therapy and Conservative Management Guidelines o More rigorous definition of the supervised, home physical-therapy requirement o Removed cognitive behavioral therapy as a conservative care modality for extremity o Conservative management requirements includes activity modification and trial of rest • Shoulder Arthroscopy and Open Procedures o Added new indications for diagnostic arthroscopy o Removed massive tear as a contraindication for revision of rotator cuff repair o Adhesive capsulitis: Added history of trauma or post-operative contracture as a requirement o Added requirement for manipulation under anesthesia/adhesive capsulitis to be consistent with arthroscopic capsular release (history of trauma or post-operative contracture o New indication for shoulder subluxation for capsulorrhaphy (Bankhart procedure) o Added new criteria for synovectomy and removed foreign body criteria o Added new indication for debridement based on coding definitions of limited vs. extensive o Removed rotator cuff tear as a criterion for tenodesis/tenotomy in patients with a clinical exam who do not meet criteria for SLAP repair or have suggestive MRI findings • Total Hip Arthroplasty o Added exception for conservative management in end-stage osteoarthritis • Hip arthroscopy o Added new indications for diagnostic arthroscopy • Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) o Removed age as an exclusion for FAIS, but further define radiographic exclusions o Added exception to failure of conservative management based on alpha angle • Knee Arthroplasty o Unicompartmental knee arthroplasty/partial knee replacement: Added degenerative change of the patellofemoral joint as a contraindication • Knee Arthroscopy o Added new indications for diagnostic arthroscopy o Added more expansive approach to physical exam findings for meniscal tears; separated chronic vs. acute o Aligned criteria for manipulation under anesthesia for debridement and lysis of adhesions o Standardized radiographic criteria to align with lateral release criteria o Added criteria for plica resection Spine Surgery • Physical Therapy and Conservative Management Guidelines o More rigorous definition of the supervised home physical therapy requirement o Removed cognitive behavioral therapy as a conservative care modality o Conservative management requirements includes activity modification and trial of rest o Added standard conservative management requirement for instability to align with spinal stenosis indications (lumbar fusion) • Lumbar Laminectomy o Added new comprehensive indication for tethered cord syndrome Sacroiliac Joint Fusion • Physical Therapy and Conservative Management Guidelines o More rigorous definition of the supervised home physical therapy requirement o Conservative management requirements includes activity modification and trial of rest Advanced Imaging of the Spine • Establish standardized definitions for phases of care continuum • Added additional complementary conservative treatment alternatives • Added exception scenarios to the physical therapy requirement • Congenital vertebral defects o New requirement for additional evaluation with radiographs • Scoliosis o Defined criteria for which presurgical planning is indicated o Requirement for radiographs and new or progressive symptoms for postsurgical imaging • Spinal dysraphism and tethered cord o Diagnostic imaging strategy limiting the use of CT to cases where MRI cannot be performed o New requirement for US prior to advanced imaging for tethered cord in infants aged 5 months or less • Multiple sclerosis o New criteria for imaging in initial diagnosis of MS • Spinal infection o New criteria for diagnosis and management aligned with IDSA and University of Michigan guidelines • Axial spondyloarthropathy o Name change from spondyloarthropathy to axial spondyloarthropathy o Defined inflammatory back pain o Diagnostic testing strategy clearly outlining radiography requirements o New indication for management in patients on biologic therapy • Cervical injury o Aligned with ACR position on pediatric cervical trauma • Thoracic or lumbar injury o Diagnostic testing strategy emphasizing radiography and limiting the use of MRI for known fracture o Remove indication for follow-up imaging of progressively worsening pain in the absence of fracture or neurologic deficits • Syringomyelia o Removed indication for surveillance imaging • Radiculopathy o Separate back pain into radicular, spinal stenosis and nonspecific low back pain. o New allowance for radiculopathy that presents as weakness without back pain. • Spinal Stenosis o New indication to cover scenarios for which imaging is indicated in spondylolisthesis, as well as indications when spinal stenosis is expected to be the cause. • Low Back Pain o Renamed to Non-specific Low Back Pain o Aligned with ACR pediatric low back pain guidelines Advanced Imaging of the Extremities • Establish standardized definitions for phases of care continuum • Added additional complementary conservative treatment alternatives • Added exception scenarios to the physical therapy requirement • Osteomyelitis or septic arthritis; myositis o Removed CT as a follow up to nondiagnostic MRI due to lower diagnostic accuracy of CT • Epicondylitis and Tenosynovitis (long head of biceps) o Guidelines removed due to lack of evidence supporting imaging for these diagnoses • Plantar fasciitis and fibromatosis o Removed CT as a follow up to nondiagnostic MRI due to lower diagnostic accuracy of CT o Added specific conservative management requirements o New indication for plantar fibromatosis • Trauma/Fracture o New indication for calcaneus fracture o Allow CT as an alternative to MRI for scaphoid fracture with delayed union or nonunion • Brachial plexus mass o Added specific requirement for suspicious findings on clinical exam or prior imaging • Morton’s neuroma o Added requirements for focused steroid injection, orthoses, plan for surgery • Adhesive capsulitis o Added requirement for planned intervention (manipulation under anesthesia or lysis of adhesions) • Rotator cuff tear; labral tear – shoulder and labral tear - hip o Defined specific exam findings and duration of conservative management o Recurrent labral tear now requires same criteria as an initial tear (shoulder only) o Required presentation of SLAP tear and longer duration of conservative management o Allowed for advanced imaging for rotator cuff tear in pediatric patients • Triangular fibrocartilage complex tear o Added requirement for radiographs and conservative management for chronic tear • Ligament tear – knee, meniscal tear o Added requirement for radiographs for specific scenarios o Increased duration of conservative management for chronic meniscal tears o Separate criteria for acute vs chronic tears • Ligament and tendon injuries – foot and ankle o Defined required duration of conservative management o Removed nondiagnostic radiograph or ultrasound from rupture indications in select clinical scenarios • Chronic anterior knee pain including chondromalacia patella and patellofemoral pain syndrome o Lengthened duration of conservative management and specified requirement for chronic anterior knee pain • Intra-articular loose body o Requirement for mechanical symptoms for advanced imaging • Osteochondral lesion (including osteochondritis dissecans, transient dislocation of patella) o New requirement for radiographs • Entrapment neuropathy o Exclude carpal and cubital tunnel o Removed requirement for conservative management when there is objective weakness on exam • Persistent lower-extremity pain o Defined duration of conservative management (6 weeks) o Exclude hip joint (addressed in other indications) • Upper-extremity pain o Exclude shoulder joint (addressed in other indications) o Diagnostic testing strategy limiting use of CT to when MRI cannot be performed or is nondiagnostic • Knee arthroplasty, presurgical planning o Medical necessity indications for MAKO and robotic assist arthroplasty cases • Perioperative imaging, not otherwise specified o Require radiographs or ultrasound prior to advanced imaging Vascular Imaging • Establish standardized definitions for phases of care continuum • Alternative non-vascular modality imaging approaches, limits combination ordering, where applicable • Hemorrhage, intracranial o Clinical scenario specification of subarachnoid hemorrhage indication. o Addition of Pediatric intracerebral hemorrhage indication. • Horner’s syndrome, pulsatile tinnitus and trigeminal neuralgia o Removal of management scenario to limit continued vascular evaluation • Stroke/TIA; Stenosis or 0cclusion (intracranial/extracranial) o Acute and subacute time frame specifications; removal of carotid/cardiac workup requirement for intracranial vascular evaluation; addition of management specifications o Sections separated anatomically into anterior/posterior circulation (carotid artery and vertebral or basilar arteries, respectively) • Aortic Aneurysm o Limits combination ordering and provides modality alternative • Pulmonary embolism o Addition of non-diagnostic chest radiograph requirement for all indications o Addition of pregnancy-adjusted YEARS algorithm • Peripheral arterial disease o Addition of new post-revascularization scenario to both upper and lower extremity PAD evaluation Thank you, Blue Cross of Idaho Healthcare Operations .
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