Clinical Appropriateness Guidelines for Radiology to be updated for AmeriHealth Members

    Effective November 10, 2019, AIM Specialty Health (AIM) will be using updated Clinical Appropriateness Guidelines for Radiology for AmeriHealth members.

    AmeriHealth has contracted with AIM to perform utilization management activities for outpatient non-emergent diagnostic imaging services and certain high-technology radiology services for our managed care members. AIM will use the updated Clinical Appropriateness Guidelines for Radiology to determine the medical necessity for these services. To view current and future guidelines, go to the Resources section of AIM’s website.

    Summary of the changes

    Effective November 10, 2019, the following changes will be implemented to the Clinical Appropriateness Guidelines for Radiology:

    Oncologic Imaging Guideline contains updates to the following:
    • Colorectal cancer, germ cell tumors, kidney cancer, multiple myeloma, prostate cancer and cancers of unknown primary / cancers not otherwise specified,
    • Removed all indications for PET scan to better align with ACR and NCCN recommendations for Kidney Cancer
    • Added Guidelines for 11C-Choline PET and 18F fluciclovine PET for Prostate Cancer
    • Added Guideline for 68Ga dotatate PET/CT for Neuroendocrine Tumors
    • Added new sections on hepatobiliary cancer and suspected metastases
    • Added allowance for MRI and/or MRCP for diagnostic workup of hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma
    • Added allowance for PET “When standard imaging prior to planned curative surgery for cholangiocarcinoma has been performed and has not demonstrated metastatic disease”

    Vascular Imaging Guideline contains updates to the following:
    • Brain, Head and Neck: Aneurysm - intracranial, Aneurysm - extracranial, Arteriovenous malformation (AVM) and fistula (AVF), Fibromuscular dysplasia, Hemorrhage - intracranial, Stenosis or occlusion - extracranial, Stenosis or occlusion - intracranial, stroke and Venous thrombosis or compression - intracranial
    • Defined use of vascular imaging as an add on test in patients following intracranial hemorrhage
    • Advanced imaging as an add on test for problem solving when ultrasound suggests a moderate or high-grade extracranial stenosis
    • Sequential diagnostic testing strategy for non-acute stroke or TIA with CTA or MRA as an add on test to change management in select circumstances for unexplained strokes for intracranial stenosis/occlusion
    • Adopted a sequential diagnostic testing strategy starting with CT or MRI for low risk groups (no risk factors and negative D-dimer) for intracranial Venous thrombosis or compression
    • Chest: Acute aortic syndrome, Aortic aneurysm, Pulmonary artery hypertension
    • Annual evaluation of stable aneurysms (new timeframe for advanced imaging, aligns with echocardiography guidelines) for Aortic aneurysm
    • New criteria for Pulmonary artery hypertension (PAH) incorporating a diagnostic testing strategy
    • Abdomen and Pelvis: Acute aortic syndrome, Aneurysm of the abdominal aorta or iliac arteries, Hematoma/hemorrhage within the abdomen or unexplained hypotension, Renal artery stenosis (RAS)/Renovascular hypertension, Venous thrombosis or compression – intracranial, Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
    • Added requirement that intra-abdominal bleeding be unexplained for advanced vascular imaging for abdomen hematoma/hemorrhage
    • Added renovascular hypertension for hypertensive crisis, new onset hypertension after age 55 with comorbidities for RAS
    • Upper Extremity: Peripheral arterial disease, Venous thrombosis or occlusion
    • Removed Raynaud’s syndrome as an indication from other vascular indications in upper extremity based on literature review
    • Lower Extremity: Added physiologic testing for peripheral arterial disease and further defined indications for classic presenting symptoms of lower extremity peripheral arterial disease
    • Added arterial ultrasound guideline content
    • Aligned peripheral arterial ultrasound with advanced vascular imaging criteria

    Imaging of the Heart Guideline contains updates to the following:
    • Blood Pool Imaging: Changes address appropriate evaluation and surveillance of LV function in patients following cardiac transplantation. Additional language is more restrictive based on the literature and aligns with the resting transthoracic echocardiography guideline.
    • Cardiac CT: Quantitative evaluation of coronary artery calcification has been revised with new more expansive language based on review of the literature.

    Policies and guidelines

    The following policies will be posted as Notifications on August 16, 2019, and will go into effect on November 10, 2019. These policies include a list of procedure codes and a link to current and future radiology guidelines on AIM’s website:

    • AmeriHealth New Jersey: #09.00.46x: High-Technology Radiology Services (New Jersey)

    • AmeriHealth Pennsylvania: #09.00.46x: High-Technology Radiology Services (Pennsylvania)

    To view the Notifications for these policies, go to our Medical Policy Portal after August 16, 2019.
    Select Accept and Go to Medical Policy Online, then select Active Notifications.

    Issued on - 08/08/2019