The Company requires precertification/preapproval through Carelon Medical Benefits Management (formerly AIM Specialty Health® (AIM)) for percutaneous coronary intervention and coronary angiography for most members enrolled in its Medicare Advantage HMO and PPO products. To direct the application of these services for these members, Carelon utilizes Medicare guidelines (e.g., National Coverage Determinations [NCD], Local Coverage Determinations [LCD]), or, in the absence of Medicare guidelines, Company medical policy. Additionally, there are certain services for which Carelon's
Clinical Appropriateness Guidelines for Cardiology are applied during the precertification/preapproval process.
For more information about the cardiology and radiology services that require precertification/preapproval, refer to the current version of policy #MA11.113: Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound.
*Carelon's medical necessity guidelines are consistent with the clinical appropriateness criteria based on technology assessment, peer-reviewed medical literature including clinical outcomes research and consensus opinion in medical practice. To access the Carelon Clinical Appropriateness Guidelines for Cardiology, click here.
