Effective October 29, 2018, updated AmeriHealth Clinical Appropriateness Guidelines for Radiology will be used by AIM Specialty Health? (AIM).
AmeriHealth has contracted with AIM to perform precertification 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. For the current guidelines, go to the Resources section of AIM?s website.
Summary of changes
The following outlines the changes to the Clinical Appropriateness Guidelines for Radiology effective October 29, 2018:
- Computed Tomography (CT) Chest
- Expanded list of diagnostic testing abnormalities that may be followed up with CT to include endoscopy, fluoroscopy, and ultrasound in addition to specific chest radiography findings
- Lengthening of timeframe required prior to imaging for chronic cough from 3 to 8 weeks, and more specifics of preliminary workup required prior to imaging
- Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging
- Allowance for use of imaging in the staging of malignancy prior to biopsy confirmation
- Allowance for imaging of suspected pulmonary embolism in pregnancy
- New criteria for appropriate imaging of chest wall mass
- Computed Tomography Angiography (CTA) Chest
- Allowance for imaging of suspected pulmonary embolism in pregnancy
- CT Abdomen/CT Pelvis/CT Abdomen & Pelvis
- Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging
- Magnetic Resonance Imaging (MRI) Chest
- New guideline for imaging of suspected pectoralis muscle tear
- New criteria for appropriate imaging of chest wall mass
- MRI Abdomen
- Addition of hemochromatosis as an indication for imaging in pediatric patients
Policies and guidelines
The following policies, which include a link to the Clinical Appropriateness Guidelines for Radiology that AIM uses and a list of procedure codes, were posted as Notifications on August 1, 2018, and will go into effect October 29, 2018:
- AmeriHealth New Jersey: #09.00.46u: High-Technology Radiology Services (New Jersey)
- AmeriHealth Pennsylvania: #09.00.46u: High-Technology Radiology Services (Pennsylvania)
To view the Notifications for these policies, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Commercial under Active Notifications.