CurrentAetnaPolicy 0432

Computerized Motion Diagnostic Imaging

Policy governing the coverage stance for computerized motion diagnostic imaging technologies (including vertebral motion analysis, DARI scan, and related markerless and marker-based systems) for Aetna members.

Policy Summary

PayerAetna

PolicyComputerized Motion Diagnostic Imaging

Policy CodePolicy 0432

Change TypeNo material changes

Effective DateOct 4, 2000

Next Review DateApr 25, 2024

Key ActionDo not submit claims for computerized motion diagnostic imaging for spinal or other indications as these services are considered experimental/investigational and not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3procedures/systems experimental

0693T, 96000-96004CPT/tracking codes

M99.00-M99.29ICD-10 examples not covered

06/08/2023last review

Coverage Criteria

Not covered — Experimental / Investigational

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Experimental/Investigational procedures: 1. Computerized motion diagnostic imaging for evaluation of the spine or any other indications; 2. DARI scan (functional motion analysis); 3. Vertebral motion analysis for evaluation of the spine or any other indications.

These procedures are listed explicitly as experimental and investigational in the policy.

ICD-10 codes M99.00–M99.29 are listed in this Clinical Policy Bulletin as examples of diagnosis codes not covered for the indications addressed by the policy. These ranges include M99.00–M99.09 (segmental and somatic dysfunction), M99.10–M99.19 (subluxation complex, vertebral), and M99.20–M99.29 (subluxation stenosis of neural canal).

Marker-less motion capture platforms (for example, the DARI scan) and optoelectronic trunk movement analyses are described in the policy background as technologies with limited, heterogeneous evidence and no established, standardized clinical protocols. The systematic review cited found relatively few studies focused on trunk motion analysis, variable marker setups, and concluded that no standard protocols have been developed, supporting a noncoverage/investigational stance for these technologies when used for clinical decision-making.

The DARI scan (a marker-less functional motion analysis platform) is noted as providing rapid full-body biomechanical reports but the policy indicates there is a lack of evidence of its effectiveness. For this reason the DARI scan is listed among procedures considered experimental and investigational and not supported by current evidence for the CPB indications.

Covered Indications

All imaging-based motion analysis modalities and indications for spinal evaluation — Experimental/Investigational

All imaging-based motion analysis modalities and indications for spinal evaluation are considered experimental/investigational under this policy.

Indications described in background literature: Various investigational uses described in the literature include quantifying intervertebral motion, assessing lumbar instability, and research applications; none are established as medically necessary per the Clinical Policy Bulletin.

Background studies evaluated accuracy, reliability and feasibility but did not establish clinical utility.

Evaluation of suspected spinal instability or trunk motion assessment — Experimental/Investigational

Evaluation of suspected spinal instability or trunk motion assessment — listed as experimental/investigational under this policy.

Studies reporting diagnostic performance: Some studies report that computer-assisted vertebral motion analysis may demonstrate greater measurement performance for detection of radiographic instability compared with flexion–extension radiographs; however, evidence is limited, heterogeneous, and standard protocols are not established, so these uses are considered investigational.

VMA performance data exist but do not establish clinical utility or standardized protocols for routine clinical decision-making.

Coding

CPT / HCPCS codes mentionedCPT

0693T	Comprehensive full body computer-based markerless 3D kinematic and kinetic motion analysis and report.
96000	Comprehensive computer-based motion analysis by video-taping and 3-D kinematics.
96001	With dynamic plantar pressure measurements during walking.
96004	Review and interpretation by physician or other qualified health care professional of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report.

ICD-10 codes listed as not covered for indications in the CPB (examples)ICD-10

M99.00-M99.09	Segmental and somatic dysfunction.
M99.10-M99.19	Subluxation complex (vertebral).
M99.20-M99.29	Subluxation stenosis of neural canal.

Provider Actions & Billing Guidance

Denial Risk

Experimental/Investigational — denial risk

Procedures listed as experimental and investigational (including computerized motion diagnostic imaging, DARI scan/functional motion analysis, and vertebral motion analysis) are at high risk for claim denial. Prior authorization will not convert experimental/investigational services to covered services.

Affected codes: CPT 0693T, 96000, 96001, 96004 (see coding block)
Denial rationale: effectiveness not established; policy designates these procedures as experimental/investigational

Denial Risk

Evidence insufficiency risk

Insufficient or inconsistent evidence and lack of standardized protocols (for example, marker-less systems such as DARI and non-gait optoelectronic trunk analyses) increase the likelihood of noncoverage or denial. Document clinical justification and cite peer-reviewed evidence when available; absence of standard protocols for marker placement and movement tasks is noted in the literature.

Evidence gaps: scarcity of studies, small sample sizes, no standard protocols for trunk motion analysis
Marker-less systems: DARI scan lacks sufficient evidence of effectiveness

Documentation Required

Administrative documentation

When submitting inquiries or appeals, reference the policy history and most recent review dates. Provide detailed clinical documentation, supporting literature, and specific ICD-10 diagnoses. Providers should consult payer guidelines for any applicable prior authorization requirements.

Policy effective date: 2000-10-04
Last review: 06/08/2023; Next review: 04/25/2024
Include: clinical notes, rationale for testing, relevant ICD-10 codes (e.g., M99.x series where applicable), and cited references

Step Therapy

Step therapy

No step therapy requirements are specified for computerized motion diagnostic imaging in this policy. Providers should follow standard utilization management processes and consult payer-specific step therapy rules if applicable.

No step therapy mandated by this policy for these procedures

Prior Authorization

Prior authorization and coverage

Prior authorization guidance: procedures designated experimental/investigational are not covered; even if prior authorization is requested, coverage will not be approved for those services. Providers should verify any payer-specific prior authorization procedures for diagnostic imaging services before submission.

Prior authorization will not override experimental/investigational determination
Consult payer rules for procedural and billing requirements

Definitions

DARI scan — definition

TermDARI scan (marker-less full-body motion capture)

DescriptionMarker-less, full-body motion capture technology platform providing full-body biomechanical analysis and reporting in as little as 5 minutes.

Use caseReported for functional motion analysis/biomechanical assessment of trunk and whole-body movement.

Evidence statusLack of evidence of clinical effectiveness noted in the policy.

Related codesReferenced in CPT/HCPCS section; no proprietary CPT code specifically required (see codes 0693T and 96000-96004 for related motion analysis services).

Vertebral motion analysis (VMA) — definition

TermVertebral motion analysis (VMA)

DescriptionComputer-assisted methods (often using fluoroscopy or video-fluoroscopy) to quantify intervertebral rotations and translations throughout a range of motion.

ModalitiesVideofluoroscopy, fluoroscopy-based quantitative motion analysis, and related computer-assisted tracking techniques.

Primary applicationQuantification of intervertebral motion to assess lumbar instability and dynamic spinal motion in research and diagnostic contexts.

VMA performance and characteristics

Key claimVMA uses controlled motion and semi-automated measurement techniques to enhance detection of radiographic instability of the lumbar spine.

Comparative performanceReported to show greater measurement performance for detecting radiographic instability compared with flexion–extension (FE) radiographs in some studies.

Technique featuresCombines controlled motion protocols with semi-automated computer measurements to quantify intervertebral rotations and translations.

Evidence limitationsFindings are from limited studies; overall literature is heterogeneous and no standard protocols established.

DARI scan — platform and evidence summary

Platform descriptionMarker-less, full-body motion capture biomechanical analysis platform that can provide reports quickly (approximately 5 minutes).

FunctionProvides comprehensive biomechanical analysis and reporting for functional motion assessment.

Evidence of clinical effectivenessPolicy notes a lack of evidence of effectiveness for DARI scan; not established as medically necessary.

Policy implicationMarker-less motion capture platforms (e.g., DARI) lack sufficient evidence and standardized protocols, supporting noncoverage/investigational stance when used for clinical decision-making.

Background

Computerized motion diagnostic imaging systems — both marker-based (optoelectronic) and marker-less platforms — are designed to quantify dynamic spinal and trunk motion and, in some implementations, to estimate biomechanical parameters or identify intervertebral motion. The literature reviewed includes small validation, reliability, and feasibility studies (for example, vertebral motion analysis and optoelectronic trunk analyses) and a systematic review of trunk movement analysis; overall the evidence is limited, heterogeneous, and lacks standardized protocols, which prevents establishing clinical utility for routine patient management.

Not Covered

Any modality of computerized motion diagnostic imaging used to evaluate the spine or other indications — including vertebral motion analysis, marker-less systems such as the DARI scan, and optoelectronic trunk movement analysis — is listed in this policy as not covered because these approaches are considered experimental and investigational due to insufficient evidence and lack of standardized clinical protocols.