December 2017 ~

Effective March 1^st, 2018, AIM Specialty Health® (AIM), will perform medical necessity review of certain elective surgeries of the spine and joints, as well as interventional pain treatment for Anthem Blue Cross Blue Shield (Anthem BCBS) fully insured members.

According to the insurer, the new musculoskeletal program reviews certain spine and joint surgeries, and interventional pain services against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine. Many of these spine and joint procedures are currently reviewed by Anthem BCBS. Medical necessity review of interventional pain treatments may be new for some states and health plans. AIM will utilize AIM guidelines to apply the review. In addition, AIM will also utilize related Anthem medical policies.

In addition, the program includes a member engagement initiative, designed to educate patients about the surgeries and treatments recommended for them, prior to the scheduled procedure. Anthem BCBS member engagement initiative supports physician efforts to reinforce important information about the surgeries and treatments recommended. The insurer says the initiative has designed to reduce anxiety, drive adherence to care plans, motivate preventive action, and improve appropriate use of care for its members.

Members are contacted by email or telephone and are provided a link to review educational multimedia programs, based on the order requests are submitted to AIM. As they view these multimedia programs, members will have an opportunity to note and submit any questions and concerns. Member input will be sent to directly to practices, giving physicians the opportunity to follow up and provide any additional education and information required.

For surgeries and pain treatment that are scheduled to begin on or after March 1^st, 2018, all providers must contact AIM to obtain a pre-service clinical review for the following non-emergency modalities:

Spinal Surgeries – cervical, thoracic, lumbar, and sacral (including all concurrent spinal procedures and all associated revision surgeries):

• Fusion surgery
• Decompression
• Disc replacement
• Surgical treatment of scoliosis
• Sacroiliac joint fusion
• Total disc arthroplasty
• Vertobroplasty/kyphoplasty

Joint Replacement (including all associated revision surgeries)

• Total knee arthroplasty
• Partial knee replacement
• Total hip arthroplasty
• Hip resurfacing
• Total shoulder arthroplasty
• Total elbow arthroplasty
• Total ankle arthroplasty

Interventional Pain Management

• Spinal cord stimulators
• Facet injections
• Epidural steroid injections
• Percutaneous neurolysis
• Peripheral nerve blocks for treatment of neuropathic pain
• Pain management devices
• Implantable pain pumps
• Radio ablations
• Sacroiliac joint

Surgeries and pain treatments performed as part of an inpatient admission are included. The program will be offered to self-funded accounts (ASO) to add to their members’ benefit package as of July 1^st, 2018 and to National Accounts as of January 1^st, 2019.

 

 

Source(s): Anthem BCBS Network Update New Hampshire;