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Musculoskeletal Services (Independence)
00.01.66f




Policy


This policy does not apply to Members for whom the AIM Specialty Health® (AIM) Musculoskeletal Services Program is not applicable. This policy only applies to members for whom the Program is applicable. Individual member benefits must be verified before/prior to providing services.

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 which will be based upon 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 their Clinical Appropriateness Guidelines to determine medical necessity for the following procedures:
  • Cervical Decompression With or Without Fusion
  • Cervical 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(percutaneous/minimally invasive techniques)
SURGICAL PROCEDURES OF THE JOINT

AIM Specialty Health® (AIM), will utilize their Clinical Appropriateness Guidelines to determine medical necessity as described below:
  • Shoulder Arthroplasty (total/partial/revision shoulder replacement)
  • Shoulder Arthroscopy and Open Procedures
  • Hip Arthroplasty (total/partial/revision hip replacement)
  • Hip Arthroscopy and Open Procedures
  • Knee Arthroplasty (total/partial/revision knee replacement)
  • Knee Arthroscopy and Open Procedures
  • Meniscal Allograft Transplantation of the Knee
  • Treatment of Osteochondral Defects
INTERVENTIONAL PAIN MANAGEMENT PROCEDURES

AIM Specialty Health® (AIM) will utilize their Clinical Appropriateness Guidelines 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
  • Spinal Cord and Nerve Root 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 will utilize the following Company medical policies to determine medical necessity for the following procedures:
  • Artificial Intervertebral Lumbar Disc Insertion​
  • 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]. 09/11/2022. Available at: http://www.aimspecialtyhealth.com/CG-Musculoskeletal.html. Accessed: April 1, 2022.

Coding

CPT Procedure Code Number(s)
Refer to Attachments A, B, and C of this policy for a complete list of codes that require preservice utilization management for spinal surgical procedures, joint surgical procedures, and interventional pain management procedures respectively.

ICD - 10 Procedure Code Number(s)
N/A

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 preservice utilization management for spinal surgical procedures, joint surgical procedures, and interventional pain management procedures respectively.

Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

9/11/2022
9/11/2022
00.01.66
Medical Policy Bulletin
Commercial
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No