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Musculoskeletal, Interventional Pain Management, Cardiology and Radiology 

Effective for dates of service on and after Oct. 1, 2024, Medica has partnered with Carelon, a utilization management (UM) program vendor, to support the provider submission and medical necessity review process for select musculoskeletal (MSK), interventional pain management, cardiology, and radiology services. Submissions and review by Carelon will replace those previously managed by NIA Magellan, with additional consideration for cardiology services. For dates of service on or after Oct. 1, 2024: submit to Carelon here.

Excluded Services

  • Procedures performed during an inpatient hospital stay are not included in the Carelon cardiology and radiology programs.
  • Procedures performed on an emergent basis at the ER and prior to the patient’s discharge from the hospital are not included in the Carelon cardiology, radiology or MSK programs. 

Tips for Success in Carelon

  • When entering an authorization in the Carelon system, it is important to specify the appropriate individual practitioner or the designated facility within the “Find Provider” request tool.
  • If the servicing provider is a facility (for example, hospital or surgery center), use the group information such as group national provider identifier (NPI), facility name, or a combination of both to enter the authorization.
  • If the servicing provider is an individual, the most efficient way to search is to enter the individual NPI in the “Group NPI” box, as there will not be a separate search function for an individual practitioner lookup.
  • Members who require the services of a provider who is not a Dean Health Plan In-Network provider may require two authorizations. The initial authorization will need to be obtained for the use of the non-network provider via Dean Health Plan Utilization Management Department.

For specific information on prior authorization, please see the applicable information below:

Carelon Cardiology Guidelines

  • Cardiac resynchronization therapy
  • Diagnostic coronary angiography
  • Endovascular revascularization
  • Imaging of the heart
  • Implantable cardioverter defibrillators
  • Permanent implantable pacemakers
  • Vascular imaging

Carelon Interventional Pain Management Guidelines

  • Epidural injection procedures and diagnostic selective nerve root blocks 
  • Paravertebral facet injection/medial branch nerve block/neurolysis 
  • Regional sympathetic nerve block 
  • Sacroiliac joint injection 
  • Spinal cord and nerve root stimulators

Carelon Musculoskeletal Spine Guidelines

  • Cervical
    • Decompression with/without fusion
    • Disc arthroplasty 
  • Lumbar
    • Discectomy, foraminotomy, and laminotomy
    • Laminectomy
    • Fusion and treatment of spinal deformity
    • Disc arthroplasty
    • Posterolateral or intertransverse lumbar fusion (autograft not feasible)
    • Sacroiliac joint fusion (percutaneous/minimally invasive techniques) 
  • Electrical bone growth stimulation, noninvasive - spine
  • Vertebroplasty/kyphoplasty
  • Bone graft substitutes and bone morphogenic proteins
  • Anterior lumbar interbody fusion (ALIF) or lateral lumbar interbody fusion

Carelon Large Joint Surgery Guidelines

Please note that authorization is required for these services regardless of place of service (inpatient, outpatient, ASC).

  • Hip
    • Arthroplasty
    • Arthroscopy and open procedures
  • Knee
    • Arthroplasty
    • Arthroscopy and open procedures
    • Autologous chondrocyte implantation of the knee
  • Shoulder
    • Arthroplasty
    • Arthroscopy and open procedures

Carelon Radiology Guidelines

Select applications of the following:

  • Ultrasound
  • Computed tomography (CT)
  • Low-dose CT 
  • Magnetic resonance imaging (MRI) 
  • Functional MRI 
  • Magnetic resonance spectroscopy 
  • Magnetic resonance cholangiopancreatography 
  • Positron emission tomography (PET) 
  • CT or MR arthrography 
  • Low-field MRI 
  • MR-guided procedures 
  • Nuclear medicine imaging 
  • Oncologic imaging 
  • Vascular imaging 

If you need technical support with the Carelon provider portal or new users at your office require registration assistance, please contact Carelon at 1-800-252-2021, option 2, weekdays 8 AM – 7 PM EDT. Please feel free to provide feedback ongoing to us via WebCustomerService@carelon.com