For orders requiring prior authorization, AIM will review requests against AIM proprietary clinical guidelines as well as health plan medical policy, and/or Local Coverage Determinations (LCDs) if applicable.
If the request meets medical necessity criteria based on the information submitted by the ordering provider’s office, the provider will receive an order number. If the request does not immediately meet criteria, the case will be forwarded to a nurse for additional clinical review. Nurse reviewers will request additional information regarding the case. If the additional information necessary confirms that the case is consistent with program guidelines, the provider will then receive an order number.
If, with the additional information the case still does not meet criteria, the case will be forwarded to a physician reviewer. Upon review, the physician reviewer may issue an order number or issue an adverse determination. The ordering provider will be notified of the final outcome for the request.
For EBRT, pre-certification is required only for procedures involving bone metastases, lung cancer (NSCLC), and breast cancer. Additionally, we are requesting that providers contact AIM to review all other 3D-conformal therapy requests on a voluntary basis.