The following updates apply by dates of services for this carrier’s Clinical Appropriate Guidelines below. This is part of their annual review process focusing on advancing efforts to provide safe, affordable and appropriate health care services.
Advanced Imaging:
Imaging of the extremities
• Shoulder arthroplasty – MRI shouldn’t be used for preoperative assessment of bone stock and bone version (computed tomography CT only)
Imaging of the spine
• Spinal infection – criteria added for imaging in patients at risk for infection based on American College of Radiology (ACR) appropriateness criteria
• Radiculopathy – Indication added for CT when being done as a myelogram; based on ACR appropriateness criteria and feedback from subject matter experts.
Vascular imaging
• Vascular anatomic delineation prior to procedures – exclusions removed for coronary artery bypass graft (CABG) and open valve replacement/repair
• Vascular anatomic delineation prior to transcatheter aortic valve implantation (TAVI/TAVE) – allowed CPT chest as an alternative to computed tomography angiography (CTA)
• Stenosis or occlusion of extracranial carotid arteries – limited screening for patients with incidentally detected carotid calcification to those undergoing preoperative evaluation for cardiac surgery; modified criteria for management of known stenosis to allow follow-up per American College of Cardiology guidelines
• Pulmonary hypertension – clarified criteria are applicable to all causes, not just pulmonary arterial hypertension
• Unexplained hypotension – indication removed as prerequisite therapy; baseline added evaluation and surveillance indications following endovascular revascularization
• Popliteal artery aneurysm – added diagnosis and management indications; added surveillance for unrepaired aneurysms to align with Society for Vascular Surgery guidelines
Reminder: Ordering and servicing providers may submit prior authorization/precertification requests to Carelon by accessing their Provider Portal directly at providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. If you have questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
