Notification

Musculoskeletal Services (Independence)


Notification Issue Date: 10/16/2018

This version of the policy will become effective on 01/14/2019.

The following services have been added to the Spine Surgical Procedures' section for this utilization management program through AIM:

  • Sacroiliac Joint Fusion

Pre-service utilization management is not in place for CPT codes 62320 and 62322, which represent epidural injection procedures, when they are performed for the following three ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain.

This policy does not apply to those members for whom Independence Administrators serves as the claims administrator or to the Company's other self-funded groups for whom the AIM Specialty Health® (AIM) Musculoskeletal Services Program is not applicable.

_________________________________________________

Note: On 01/10/2019 the following 01/01/2019 CPT procedure codes were added to Attachment A.: 20932, 20933, 20934. These codes have become part of the Musculoskeletal Services utilization management program through AIM Specialty Health®.



Medical Policy Bulletin


Title:Musculoskeletal Services (Independence)

Policy #:00.01.66b

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.


Refer to the following News Articles:
Meniscal allograft transplantation performed in combination with treatment of focal articular cartilage lesions
Minimally invasive fusion/stabilization of the sacroiliac joint using a titanium triangular implant

This policy does not apply to those members for whom Independence Administrators serves as the claims administrator or to the Company's other self-funded groups for whom the AIM Specialty Health® (AIM) Musculoskeletal Services Program is not applicable.

The intent of this policy is to communicate that the Company has delegated the responsibility for utilization management activities to AIM Specialty Health® (AIM) for select musculoskeletal services will be based upon either the Company’s medical policies or AIM’s Clinical Appropriateness Guidelines.

Experimental and investigational services are services whose safety or efficacy is not known, or are services that are used in a way that departs from generally accepted standards of practice in the medical community. As such precertification/preapproval for these procedures may be denied by AIM as not medically necessary (NMN) when AIM uses its clinical guidelines.

Refer to the References section of this policy for a link to the AIM Speciality Health Clinical Appropriateness Guidelines for the spinal surgical procedures, joint surgical procedures, and interventional pain management procedures that are part of this program. Refer to Attachments A, B, and C of this policy for a complete list of codes that require precertification for spinal surgical procedures, joint surgical procedures, and interventional pain management procedures respectively.

SPINAL SURGICAL PROCEDURES

AIM Specialty Health® (AIM) will utilize either Company medical policy, or in the absence of a specific Company medical policy, AIM will utilize their Clinical Appropriateness Guidelines to determine medical necessity for the following procedures:
  • Cervical Decompression With or Without Fusion
  • Cervical Disc Arthroplasty
  • Lumbar Disc Arthroplasty
  • Lumbar Discectomy, Foraminotomy, and Laminotomy
  • Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
  • Lumbar Laminectomy
  • Noninvasive Electrical Bone Growth Stimulators (spinal)
  • Vertebroplasty/Kyphoplasty
  • Bone Graft Substitutes and Bone Morphogenetic Proteins
  • Sacroiliac Joint Fusion

AIM utilizes the following Company medical policies to determine medical necessity for the following procedures:
  • Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
  • Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
  • Artificial Intervertebral Disc Insertion
  • Spinal Fusion
  • Spinal Laminectomy
  • Spinal Discectomy
  • Experimental/Investigational Services

AIM utilizes their Clinical Appropriateness Guidelines to determine medical necessity for the following procedures:
  • Bone Graft Substitutes and Bone Morphogenetic Proteins
  • Sacroiliac Joint Fusion


SURGICAL PROCEDURES OF THE JOINT

AIM Specialty Health® (AIM), will utilize either Company medical policy, or in the absence of a specific Company medical policy position, AIM will utilize their Clinical Appropriateness Guidelines to determine medical necessity as described below:
  • Shoulder Arthroplasty
  • Shoulder Arthroscopy and Open Procedures
  • Hip Arthroplasty
  • Hip Arthroscopy and Open Procedures
  • Knee Arthroplasty
  • Knee Arthroscopy and Open Procedures
  • Meniscal Allograft Transplantation of the Knee
  • Treatment of Osteochondral Defects

AIM utilizes the following Company medical policies to determine medical necessity:
  • Meniscal Allograft Transplantation
  • Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
  • Osteochondral Autograft Transplantation (OAT) Procedure
  • Osteochondral Allograft Transplantation
  • Surgical Treatment of Femoroacetabular Impingement
  • Experimental/Investigational Services

AIM utilizes their Clinical Appropriateness Guidelines to determine medical necessity for the following:
  • Shoulder Arthroplasty
  • Shoulder Arthroscopy and Open Procedures
  • Hip Arthroplasty
  • Hip Arthroscopy and Open Procedures (other than Surgical Treatment of Femoroacetabular Impingement, where Company medical policy will be used by AIM)
  • Knee Arthroplasty
  • Knee Arthroscopy and Open Procedures

INTERVENTIONAL PAIN MANAGEMENT PROCEDURES

AIM Specialty Health® (AIM) will utilize Company medical policies to determine medical necessity for the following procedures:
  • Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks*
  • Paravertebral Facet Injection/Nerve Block/Neurolysis
  • Regional Sympathetic Nerve Block
  • Sacroiliac Joint Injection
  • Implantation of Spinal Cord Stimulators

* Pre-service utilization management is not in place for CPT codes 62320 and 62322, which represent epidural injection procedures, when they are performed for the following three ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain.

AIM utilizes the following Company medical policies to determine medical necessity for the following procedures:
  • Treatments of Complex Regional Pain Syndrome (CRPS)
  • Spinal Cord and Dorsal Root Ganglion Stimulation
  • Denervation of the Spinal Nerves for Chronic Pain
  • Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
  • Experimental/Investigational Services

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, spinal surgical procedures, joint surgical procedures, and interventional pain management procedures are covered under the medical benefits of the Company’s products when the medical necessity criteria for the services are met.

Description

The Company has delegated the responsibility for utilization management activities of select spinal surgical procedure, joint surgical procedures, and interventional pain management procedures to AIM Specialty Health® (AIM). AIM uses our Company's medical policies or its Clinical Appropriateness Guidelines to determine medical necessity for the select spinal surgical procedures, joint surgical procedures, and interventional pain management procedures. Multiple sources were used to develop these medical policies and guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice.
References


American Imaging Management (AIM) Specialty Health® Clinical Appropriateness Guidelines for Musculoskeletal. [AIM Web site]. Available at: http://www.aimspecialtyhealth.com/CG-Musculoskeletal.html. Accessed: 10/12/2018.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Attachments A, B, and C of this policy for a complete list of codes that require precertification for spinal surgical procedures, joint surgical procedures, and interventional pain management procedures respectively.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



Refer to Attachments A, B, and C of this policy for a complete list of codes that require precertification for spinal surgical procedures, joint surgical procedures, and interventional pain management procedures respectively.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Musculoskeletal Services (Independence)
Description: Procedure Codes for Spinal Surgery

Attachment B: Musculoskeletal Services (Independence)
Description: Procedure Codes for Joint Surgery

Attachment C: Musculoskeletal Services (Independence)
Description: Procedures Codes for Interventional Pain Management




Policy History

Revisions for 00.01.66b
01/14/2019This version of the policy will become effective on 01/14/2019.

The following services have been added to the Spine Surgical Procedures' section for this utilization management program through AIM:
  • Sacroiliac Joint Fusion

Pre-service utilization management is not in place for CPT codes 62320 and 62322, which represent epidural injection procedures, when they are performed for the following three ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain.

This policy does not apply to those members for whom Independence Administrators serves as the claims administrator or to the Company's other self-funded groups for whom the AIM Specialty Health® (AIM) Musculoskeletal Services Program is not applicable.

_________________________________________________

On 01/10/2019 the following 01/01/2019 CPT procedure codes were added to Attachment A.: 20932, 20933, 20934. These codes have become part of the Musculoskeletal Services utilization management program through AIM Specialty Health®.

Revisions for 00.01.66a
03/01/2018This version of the policy will become effective 03/01/2018.

The following new policy has been updated to communicate the Company’s delegation of precertification/preapproval of select interventional pain management procedures to AIM Specialty Health® (AIM).

Revisions for 00.01.66a
03/01/2018This version of the policy will become effective 03/01/2018.

The following new policy has been updated to communicate the Company’s delegation of precertification/preapproval of select interventional pain management procedures to AIM Specialty Health® (AIM).

00.01.66
01/02/2018Effective 10/05/2017 this policy has been updated to the new policy template format.

This version of the policy will become effective 01/02/2018.

The following new policy has been developed to communicate the Company’s delegation of precertification/preapproval of select spinal and joint surgeries to AIM Specialty Health® (AIM).

Policy section was updated on 11/02/2017 to further clarify instances of when AIM Specialty Health® Clinical Appropriateness Guidelines will be used during precertification/preapproval. The effective date of this policy remain as 01/02/2018.

The following procedure codes were removed from Attachment A of this policy (on 11/02/2017), and are not part of precertification/preapproval of musculoskeletal services with AIM Specialty Health® (AIM):

20974, 22586, 0164T, and 0165T.

Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A

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