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Musculoskeletal Services
MA00.047f




Policy

The intent of this policy is to communicate that utilization management by AIM Specialty Health® (AIM) of select musculoskeletal services will be based upon Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no Medicare guidelines exist, utilization management of select musculoskeletal services by AIM will be based upon AIM’s Clinical Appropriateness Guidelines with the exception of services performed in the emergency room or during an inpatient or observation unit stay.​

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 Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD])  or in the absence of a specific Medicare guideline, 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
SURGICAL PROCEDURES OF THE JOINT

​AIM Specialty Health® (AIM) will utilize Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD])  or in the absence of a specific Medicare guideline, AIM will utilize their Clinical Appropriateness Guidelines to determine medical necessity for the following procedures:​

  • 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 Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD])  or in the absence of a specific Medicare guideline, 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
AIM utilizes the following Company medical policies to determine medical necessity: 
  • 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

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare. 

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, spinal and joint surgical procedures are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria for the services are met.

Coverage determinations for the spinal surgical procedures, joint surgical procedures, and interventional pain management procedures will be based on the National Coverage Determination (NCD) and/or Local Coverage Determination (LCD). If an NCD and LCD do not exist, the AIM Specialty Health® (AIM) Clinical Appropriateness Guidelines will apply.

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 Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]) for this utilization management. If no Medicare guidelines exist, utilization management of select musculoskeletal services by AIM will be based upon AIM’s Clinical Appropriateness Guidelines. 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
MA00.047
Medical Policy Bulletin
Medicare Advantage
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No