Representatives from APMA, AAOS, ACFAS, and AOFAS (specialty societies) held a virtual meeting with Anthem and its subsidiary AIM on March 3 to discuss our concerns with their Clinical Appropriateness Guidelines for the Musculoskeletal Program, Appropriate Use Criteria: Small Joint Surgery (Clinical Guidelines) and provide our suggested changes.
In October 2020, APMA along with the other specialty societies wrote to Anthem/AIM detailing our concerns. APMA also formed an internal workgroup led by APMA Trustee Lawrence Santi, DPM, that is tasked with reviewing the guidelines and coordinating efforts with the other stakeholders.
On the call, representatives from the specialty societies addressed the problems with Anthem/AIM’s process for obtaining prior authorizations including requesting a peer-to-peer review, and AIM acknowledged these problems and assured us that they resolved them.
Anthem/AIM agreed to address some of our concerns with their ankle reconstructions guidelines. Specifically, ankle arthroplasties, including implants, will now be added to the clinical guidelines if the arthrodesis has failed and there is now a non- or mal-union. The patient must be symptomatic. Progressive peripheral neuropathy and immune-suppressed patients will be recommended to be removed from the exclusions for ankle arthroplasties if the patients are symptomatic.
Anthem/AIM partially addressed our concerns with the implant arthroplasty for hallux limitus/rigidus. It was recommended that the double-stemmed silastic implants (Swanson design) be removed from the exclusions. Cemented implants, however, will continue to remain under the exclusions. Anthem/AIM stated that more literature is needed from the specialty societies regarding the efficacy of other types of implants such as hemi-implants and implants made of other materials.
Anthem/AIM and the specialty societies agreed to future meetings to address concerns with Anthem/AIM’s guidelines for percutaneous osteotomies and intramedullary fixation and hammertoe repairs, and in the interim, Anthem/AIM will consider written comments.
APMA’s Anthem Workgroup is scheduled to meet again later this month to plan our strategy going forward.