The Company requires precertification/preapproval through Carelon Medical Benefits Management (formerly AIM Specialty Health® (AIM)) for select musculoskeletal services 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 Musculoskeletal* are applied during the precertification/preapproval process.
For more information about the musculoskeletal services that require precertification/preapproval, and for a list of services that follow Company medical policy or Carelon Guidelines, refer to the current version of medical policy #MA00.047: Musculoskeletal Services.
*Carelon's medical necessity guidelines are consistent with the clinical appropriateness criteria based on technology assessment, peer-reviewed medical liter ature including clinical outcomes research and consensus opinion in medical practice. To access the Carelon Clinical Appropriateness Guidelines for Musculoskeletal, click here.
