Effective November 1, 2020, AIM Specialty Health® (AIM)*, a specialty health benefits company, will expand the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joint for Medicare Advantage (MA) patients, as further outlined below.


AIM will follow the Empire BlueCross BlueShield (Empire) clinical hierarchy for medical necessity determination. For Medicare Advantage products AIM makes clinical appropriateness based on CMS National Coverage Determinations, Local Coverage Determinations, other coverage guidelines, and instructions issued by CMS and legislative benefit changes. Where the existing CMS guidance provides insufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.


Prior authorization requirements

For services scheduled on or after November 1, 2020, providers must contact AIM to obtain prior authorization for the services detailed below. Providers are strongly encouraged to verify they have received a prior authorization before scheduling and performing services.


Detailed prior authorization requirements are available to contracted providers by accessing the Availity Portal* at www.availity.com. Contracted and non-contracted providers may call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements or additional questions as needed.


Small joint replacement (including all associated revision surgeries)

  • Total joint replacement of the ankle
  • Correction of hallux valgus
  • Hammertoe repair


The expanded musculoskeletal program will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (Level of Care review). Procedures performed as part of an inpatient admission are included. The clinical guidelines that have been adopted by Empire BlueCross BlueShield to review for medical necessity and level of care are located at:


How to place a review request

You may place a prior authorization request online via the AIM ProviderPortalSM. This service is available 24/7 to process requests using Clinical Criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 7 a.m. to 7 p.m. Central time.


For more information

For resources to help your practice get started with the musculoskeletal program, go to www.aimprovider.com/msk.


This provider website will help you learn more and provide useful information and tools such as order entry checklists, clinical guidelines, and FAQs.


For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com


EBSCRNU-0122-20 June 2020



Featured In:
August 2020 Empire Provider News