CurrentAetnaPolicy 0628

Spinal Ultrasound

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This clinical policy bulletin addresses when ultrasound of the spine and paraspinal tissues is considered medically necessary, investigational, or not covered, and lists applicable procedure and diagnosis codes. It applies to Aetna coverage determinations and providers submitting claims.

Policy Summary

PayerAetna

PolicySpinal Ultrasound

Policy CodePolicy 0628

Change TypeNo material change

Effective DateJun 28, 2002

Last ReviewSep 12, 2023

Next Review DateJul 11, 2024

Key ActionObtain prior authorization when billing CPT 76800 unless documentation supports a covered neonatal/infant or intra-operative indication.

SourceLink

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAetnaPolicy 0628

Spinal Ultrasound

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Policy Summary

PayerAetna

PolicySpinal Ultrasound

Policy CodePolicy 0628

Change TypeNo material change

Effective DateJun 28, 2002

Last ReviewSep 12, 2023

Next Review DateJul 11, 2024

Key ActionObtain prior authorization when billing CPT 76800 unless documentation supports a covered neonatal/infant or intra-operative indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered CPT code listed

7+Neonatal/infant indications enumerated

2Situations explicitly covered

2SonixGPS discussed as investigational

~57Bibliographic references

09/12/2023Policy last reviewed

Coverage Criteria

Medically necessary indications

Aetna considers spinal ultrasound medically necessary when ALL of the following groups apply (grouped by context):

Neonatal/Infant Indications: In newborns and infants for any of the following: detection of sequelae of injury (eg, hematoma after spinal tap or birth injury; post‑traumatic cerebrospinal fluid leak; sequelae of prior instrumentation, infection, or hemorrhage); evaluation of suspected defects such as cord tethering, diastematomyelia, hydromyelia, and syringomyelia; guidance for lumbar puncture; lumbosacral stigmata associated with spinal dysraphism; post‑operative assessment for cord retethering; evaluation across the spectrum of caudal regression syndrome (eg, anal atresia or stenosis; sacral agenesis); visualization of fluid with characteristics of blood products within the spinal canal in neonates/infants with intracranial hemorrhage.

Intra-operative Use: Spinal ultrasound performed intra‑operatively.

Experimental and investigational

The following are considered experimental and investigational (use of ultrasound is NOT established):

Adult diagnostic or non‑operative uses: Diagnostic ultrasound of the spine and paraspinal tissues for evaluation of neuromusculoskeletal conditions and all other indications in adults (eg, evaluation of curve flexibility before surgical intervention for scoliosis; evaluation and management of spinal epidural abscess; routine neuraxial blocks; to assist lumbar puncture except in newborns/infants).

SonixGPS (real‑time needle‑tracking): SonixGPS (an electromagnetic real‑time ultrasound‑guided spinal anesthesia/needle‑tracking system) is considered experimental and investigational because effectiveness has not been established.

Evidence summaries — SonixGPS, pre-procedural lumbar US, nerve US

Findings from the literature for specific applications:

SonixGPS real‑time US‑guided neuraxial anesthesia: Small case reports, case series, and feasibility studies (examples described in the literature include case report(s) and series with ~20 patients) report that SonixGPS is feasible, may reduce needle attempts, and can simplify out‑of‑plane approaches, but current evidence is limited to small observational and feasibility studies; larger randomized trials are needed.evidence: case reports/series, feasibility

Class of evidence: limited (feasibility/case series)

Pre‑procedural lumbar neuraxial ultrasound benefits: Systematic reviews and meta‑analyses of randomized trials (32 trials, 3,439 patients) demonstrated decreased technical failure (RR 0.69), increased first‑attempt success (RR 1.5; NNT=5), and fewer needle re‑directions; effects were larger in difficult spines/obese patients (RR 1.84; NNT=3).evidence: RCTs pooled

Class of evidence: pooled RCTs/meta‑analysis

Aetna considers non‑operative spinal/paraspinal ultrasound in adults to be investigational/not established for diagnostic evaluation. Examples of adult clinical contexts explicitly listed include evaluation of dorsopathies, intervertebral disc disorders, scoliosis/curve assessment, dorsalgia (back pain), radiculopathy, and other neuromusculoskeletal conditions of the spine and paraspinal tissues. Corresponding ICD‑10 categories cited as not covered for these non‑neonatal adult indications include M41.x (scoliosis), M50.x–M51.x (intervertebral disc disorders), M53.x (other dorsopathies), M54.x (dorsalgia), and related nervous system and peripheral nerve disorder codes (for example, G54.0–G59), among others.

Spinal ultrasound is not described as an appropriate diagnostic tool for suspected spinal epidural abscess (SEA). When the clinical presentation and risk profile suggest SEA, the policy and cited literature state that gadolinium‑enhanced MRI of the spine should be obtained emergently to delineate the location and neural compressive effects of an abscess; spinal ultrasound is not presented as a management or primary diagnostic modality in this context.

This Clinical Policy Bulletin is a summary to assist in administering plan benefits and is not a contract. It provides a partial, general description of covered services and exclusions; specific member benefits, limitations, and exclusions are determined by the member's contract, and providers should consult plan documents and prior‑authorization procedures for definitive coverage decisions.

Diagnostic spinal or paraspinal ultrasound performed in adults for evaluation of back pain, radicular symptoms, or other non‑neonatal indications is considered investigational / not medically necessary. Professional society statements and the policy note insufficient evidence to support routine diagnostic use of spinal ultrasound in adults compared with established modalities such as CT or MRI.

Indications Considered Covered

Neonatal/infant spinal ultrasound indications

Neonatal/infant spinal ultrasound indications: Indications in neonates and young infants include detection of sequelae of injury (hematoma after spinal tap or birth injury; post‑traumatic CSF leak; sequelae of prior instrumentation, infection, or hemorrhage); evaluation of suspected defects (cord tethering, diastematomyelia, hydromyelia, syringomyelia); guidance for lumbar puncture; lumbosacral stigmata associated with spinal dysraphism; post‑operative assessment for cord retethering; evaluation of caudal regression spectrum (eg, anal atresia or stenosis; sacral agenesis); and visualization of blood‑characteristic fluid within the spinal canal in neonates/infants with intracranial hemorrhage.

Intra-operative spinal ultrasound

Intra‑operative spinal ultrasound: Spinal ultrasound performed intra‑operatively is considered medically necessary.

Neuraxial procedural assistance (adjunct)

Coding

Covered CPT Codes (if selection criteria met)CPTCovered

76800

Ultrasound, spinal canal and contents

Related CPT Codes referencedCPT

62320-62323	Injection(s) of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid
62324-62327	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid
64400-64530	Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic

ICD-10 Codes Covered (if selection criteria met)ICD-10Covered

G96.0	Cerebrospinal fluid leak [post-trauma]
G97.51	Postprocedural hemorrhage of a nervous system organ or structure following a nervous system procedure [following lumbar puncture]
G97.61	Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure
G97.63	Postprocedural seroma of a nervous system organ or structure following a nervous system procedure
P10.0-P10.3, P10.8-P10.9	Subdural and cerebral hemorrhage [due to birth trauma]
P11.5	Birth injury to spine and spinal cord
P52.0-P52.22	Intracranial nontraumatic hemorrhage of newborn
P52.3	Unspecified intraventricular (nontraumatic) hemorrhage of newborn
P52.5	Subarachnoid (nontraumatic) hemorrhage of newborn
Q05.0-Q05.9	Spina bifida

1–10 of 15

1/2

ICD-10 Codes Not Covered (examples)ICD-10Not Covered

G06.1	Intraspinal abscess and granuloma
G54.0-G59	Nerve, nerve root and plexus disorders
G60.0-G65.2	Polyneuropathies and other disorders of the peripheral nervous system
G70.00-G73.7	Diseases of myoneural junction and muscle
M41.00-M41.9	Scoliosis
M50.00-M51.9, M51.A0-M51.A5	Cervical, thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders
M53.0-M53.9	Other and unspecified dorsopathies
M54.00-M54.9	Dorsalgia

Age limitation for optimal imaging

Optimal age windowMost successful in the newborn period and early infancy; in infants older than 6 months the examination can be very limited.

ReasonSonographic examination is performed through incompletely ossified posterior elements, which enables visualization in neonates and young infants.

Limitations after 6 monthsIn infants older than 6 months visualization is often limited though the level of termination of the cord may still be identified.

Clinical implicationPrefer ultrasound for spinal imaging indications in neonates/early infants (e.g., guidance for lumbar puncture, evaluation of dysraphism) rather than in older infants or adults.

Provider Actions / Billing Guidance

Prior Authorization

Prior authorization may be required for CPT 76800

Prior authorization may be required when billing CPT 76800; submit documentation that the study meets the policy's selection criteria (neonate/infant covered indications or intra-operative use).

CPT 76800: Ultrasound, spinal canal and contents
Include ICD-10 code(s) corresponding to covered neonatal/infant indications or intra-operative context

Prior Authorization

Prior authorization may be needed for SonixGPS-guided procedures

When SonixGPS or other proprietary real-time needle-tracking systems and associated proprietary needles are used, prior authorization may be required to justify use of specialized equipment and consumables.

SonixGPS is an electromagnetic needle-tracking system used for real-time US-guided neuraxial procedures
Evidence is limited to case reports/series and feasibility studies

Prior Authorization Notes

Prior Authorization

Prior authorization required for CPT 76800 unless covered indication documented

Prior authorization is required when billing CPT 76800 unless documentation supports that the study was performed for a covered neonatal/infant indication or intra-operatively.

CPT 76800: Ultrasound, spinal canal and contents
Ensure submitted documentation matches policy-covered neonatal/infant indications or intra-operative use

Prior Authorization

Prior authorization may be required for real-time US with needle-tracking (SonixGPS)

When real-time ultrasound is performed with needle-tracking equipment (e.g., SonixGPS) and proprietary needles, prior authorization may be required to justify use of specialized equipment and consumables.

SonixGPS displays current and predicted needle tip position on the ultrasound screen in real time
Provide justification and supporting evidence due to limited current effectiveness data

Contrast and Imaging Rules

Billing Rule

Contrast/imaging guidance for suspected SEA

When contrast or alternative imaging is indicated, follow clinical guidance: for suspected spinal epidural abscess, obtain gadolinium-enhanced MRI emergently rather than relying on spinal ultrasound.

SEA investigations require emergent gadolinium-enhanced MRI of the spine
Spinal ultrasound is not recommended as the diagnostic modality for SEA

Billing Rule

Suspected spinal epidural abscess — obtain gadolinium-enhanced MRI; spinal US not recommended

For suspected spinal epidural abscess, do not use spinal ultrasound for diagnosis; obtain emergent gadolinium-enhanced MRI of the spine as the diagnostic study of choice.

SEA often requires prompt MRI with gadolinium to delineate abscess location and neural compression

Not Covered / Exclusions

Non‑operative spinal and paraspinal ultrasound in adults used for diagnostic evaluation—such as assessment of back pain, radiculopathy, paraspinal masses, or other neuromusculoskeletal spinal conditions—is considered not covered / investigational. The policy lists adult ICD‑10 groups and examples (for instance, dorsopathies, intervertebral disc disorders, scoliosis, and dorsalgia) as contexts in which ultrasound is not established for diagnostic use in adults.

Use of spinal ultrasound as the primary diagnostic modality for suspected spinal epidural abscess is not covered. The referenced clinical reviews emphasize that when SEA is suspected, gadolinium‑enhanced MRI is the diagnostic imaging study of choice and should be obtained emergently; spinal ultrasound is not described as an appropriate management tool in the evaluation of SEA.

Background

Spinal ultrasound is a noninvasive imaging technique primarily useful in newborns and young infants because the posterior bony elements are incompletely ossified, permitting sonographic visualization of the spinal canal and cord. Professional society guidance and reviews historically limit routine diagnostic use in adults owing to insufficient evidence of diagnostic accuracy compared with CT or MRI. Ultrasound is also used intra‑operatively and as an adjunct to neuraxial procedures, where evidence supports improved localization and procedural precision in selected situations.

Definitions

Neuraxial US — definition

DefinitionNeuraxial ultrasound: ultrasound imaging used to identify intervertebral levels, estimate depth to the epidural or intrathecal space, and to guide needle placement for spinal or epidural anesthesia.

Primary usesLocalization of intervertebral levels, depth estimation to epidural/intrathecal space, and procedural guidance for neuraxial blocks.

ContextUsed as an adjunct for neuraxial procedures; routine diagnostic neuraxial use in adults is considered investigational.

SonixGPS — electromagnetic needle-tracking system

What it isAn electromagnetic needle-tracking system (SonixGPS) that displays current and predicted needle tip position on the ultrasound screen in real time to facilitate needle-beam alignment.

Intended use

Evidence and References

Evidence summaries — SonixGPS, pre-procedural lumbar US, nerve US (for content writer)

Findings from the literature for specific applications (summary for content writers):

SonixGPS summary: Small case reports/series and feasibility studies report feasibility and acceptable success rates (eg, 70–90% in small series), reduced needle attempts in many patients, and potential simplification of out‑of‑plane approaches; evidence limited to small observational studies and feasibility trials.evidence: case‑series/feasibility

See SonixGPS case report and case‑series (Wong et al., Brinkman et al., Niazi et al.)

Pre‑procedural lumbar US summary: Systematic review/meta‑analysis of 32 RCTs (3,439 patients) showed decreased technical failure (RR 0.69), increased first‑attempt success (RR 1.5; NNT=5), and fewer needle re‑directions; benefits were greater in difficult spines/obese subgroups (RR 1.84; NNT=3).evidence: meta‑analysis

See Sidiropoulou et al.; Perlas et al.

Revision History

2002-06-28effective_date

Policy originally became effective.

2023-09-12last_review

Policy last reviewed on 09/12/2023; content and references updated as applicable.

2024-07-11next_reviewLatest

Next scheduled policy review date.

Policy Summary

PayerAetna

PolicySpinal Ultrasound

Policy CodePolicy 0628

Change TypeNo material change

Effective DateJun 28, 2002

Last ReviewSep 12, 2023

Next Review DateJul 11, 2024

Key ActionObtain prior authorization when billing CPT 76800 unless documentation supports a covered neonatal/infant or intra-operative indication.

SourceLink

On This Page

Nerve ultrasound for chronic inflammatory neuropathies:

Prospective cohort data and case series (eg, Herraets et al.) show high sensitivity (97.4%) for nerve ultrasound and complementary diagnostic value to nerve conduction studies for detecting treatment‑responsive chronic inflammatory neuropathies (eg, CIDP, MMN); nerve US added ~21.1% in detection of treatment‑responsive cases in a 100‑patient cohort.

evidence: cohort, case series

Class of evidence: prospective cohort (Class IV) and case series

Neuraxial procedural assistance (adjunct): Ultrasound may be used as an adjunct to identify intervertebral levels, estimate depth to the epidural/intrathecal space, and guide needle placement for neuraxial anesthesia. Routine diagnostic use of spinal US in adults remains investigational; neuraxial US is supported as a technique to improve precision but evidence on adult outcomes is limited.

Pre-procedural ultrasound to facilitate neuraxial needle placement

Pre‑procedural lumbar US indicated: Pre‑procedural ultrasound of the lumbar spine to facilitate neuraxial needle placement is indicated to reduce technical failure and increase first‑attempt success, particularly in patients with difficult spines or obesity (evidence from pooled RCTs: 32 trials, 3,439 patients; RR for 1st‑attempt success 1.5, NNT=5 overall; NNT=3 in difficult/obese subgroup).evidence: meta‑analysis

Nerve ultrasound for suspected chronic inflammatory neuropathies (e.g., CIDP, MMN)

Nerve ultrasound indicated: Consider nerve ultrasound as a complementary diagnostic tool when evaluating suspected chronic inflammatory neuropathies (eg, CIDP, MMN) to detect focal nerve enlargement and improve detection of treatment‑responsive cases; evidence includes prospective cohort data demonstrating sensitivity 97.4% and added diagnostic yield compared to nerve conduction studies.evidence: cohort and case series

Real-time ultrasound with needle-tracking (SonixGPS) for neuraxial blockade

SonixGPS (real‑time ultrasound with needle‑tracking): Real‑time ultrasound with electromagnetic needle‑tracking (SonixGPS) for neuraxial blockade is considered experimental/investigational; available evidence is limited to feasibility studies, case reports, and small case series reporting acceptable feasibility and success rates but insufficient evidence to establish effectiveness for routine use. Use, if considered, should be on a case‑by‑case basis and may require prior authorization for specialized equipment and proprietary needles.

Documented clinical studies and guidelines

Documented clinical studies and guidelines: The policy references multiple clinical studies, systematic reviews, meta‑analyses, and professional society statements addressing neonatal spinal sonography, neuraxial ultrasound techniques, pre‑procedural lumbar US, nerve ultrasound, and needle‑tracking feasibility (approximately 50+ references including ACR, AIUM, RCTs, meta‑analyses, cohort studies, and case series).

Prior Authorization

No blanket prior-authorization specification for all spinal US

This policy section does not list specific universal prior authorization rules for all spinal ultrasound studies; check member benefits and prior-auth requirements for individual cases.

The Clinical Policy Bulletin is a partial description of plan benefits and may be updated; verify coverage and authorization requirements with the plan

Denial Risk

Denial risk for investigational adult or SonixGPS uses

Claims for spinal/paraspinal ultrasound in adults for non-operative diagnostic evaluation or for indications listed as investigational (including SonixGPS) are subject to denial.

Adult diagnostic/non-operative uses (e.g., back pain, radiculopathy) are considered experimental/investigational
SonixGPS is listed as experimental and investigational

Step Therapy

Stepwise use of pre-procedural lumbar ultrasound

Use a stepwise approach for pre-procedural lumbar ultrasound: consider standard palpation techniques first and reserve pre-procedural US when clinical factors (e.g., difficult spine, obesity) suggest benefit, as evidence shows improved first-attempt success and fewer needle re-directions particularly in difficult spines.

Pre-procedural US decreased technical failure and increased first-attempt success (NNT = 5 overall; NNT = 3 in difficult/obese patients)
Document rationale if pre-procedural US is used up-front for clinical reasons

Note

Document justification for novel equipment-guided procedures

When seeking coverage for novel equipment-guided procedures, provide case justification and supporting evidence; SonixGPS-related procedures have limited evidence and may require prior review.

Case reports and small series report feasibility but larger trials are lacking
Be prepared to document why specialized needle-tracking is necessary for the patient

Documentation Required

Document neonatal/infant status and listed indication

When submitting claims for spinal ultrasound for covered neonatal/infant indications, include documentation that the patient is a newborn or infant and that the indication matches one of the policy-listed neonatal/infant criteria.

Examples of covered neonatal/infant indications include detection of sequelae of injury, evaluation of suspected defects (tethering, diastematomyelia, hydromyelia, syringomyelia), guidance for lumbar puncture, lumbosacral stigmata associated with dysraphism, post-op assessment for cord retethering, caudal regression spectrum, and visualization of blood-characteristic fluid with intracranial hemorrhage
Age limitation: most successful in newborn and early infancy; limited in infants older than 6 months

Documentation Required

Document indication, procedure and needle details for pre-procedural lumbar US

For pre-procedural lumbar US used to facilitate neuraxial procedures, document the clinical indication (e.g., difficult spine, obesity), procedure details (number of needle passes, approach), and needle information and outcomes to support clinical benefit.

Record indication (difficult spine, obesity, prior surgery), needle passes and re-directions, approach (in-plane vs out-of-plane), and first-attempt success or need for conversion
Include outcomes to substantiate the clinical benefit claimed

Note

Providers responsible for treatment decisions and benefit verification

Clinical Policy Bulletins are a partial description of plan or program benefits and do not constitute a contract; providers are responsible for treatment decisions and for verifying member-specific coverage and prior authorization requirements.

Providers are solely responsible for medical advice and treatment of members
Verify plan provisions for coverage details and prior authorization

Denial Risk

Denial risk for investigational uses

Claims for investigational or experimental uses (including non-operative adult diagnostic spinal/paraspinal ultrasound and SonixGPS use) may be denied as effectiveness has not been established.

Non-operative adult diagnostic spinal/paraspinal ultrasound is considered investigational
SonixGPS is expressly listed as experimental and investigational

Denial Risk

Do not use spinal US to diagnose suspected spinal epidural abscess — obtain gadolinium-enhanced MRI

Spinal ultrasound is not described as an appropriate diagnostic tool for suspected spinal epidural abscess; obtain gadolinium-enhanced MRI of the spine emergently when SEA is suspected.

MRI with gadolinium is the diagnostic imaging modality of choice for SEA
Spinal ultrasound is not mentioned as a management tool for SEA in reviews and guidance

Note

No specific authorization or denial triggers stated

This section does not specify particular authorization or denial triggers for all studies; follow plan-specific prior authorization processes and provide supporting documentation as requested.

No specific authorization/denial triggers are stated in this part of the document
Contact the plan for case-by-case prior-authorization requirements

Spinal US is not mentioned as a management or diagnostic tool for SEA in clinical reviews

Facilitates real-time ultrasound-guided spinal anesthesia and other advanced US-guided regional anesthesia techniques where needle-beam alignment is critical.

Evidence statusDescribed in small case reports and series; effectiveness for routine use remains investigational pending larger trials.

SonixGPS (term)

TermSonixGPS

Short descriptionElectromagnetic needle-tracking system for real-time ultrasound-guided spinal anesthesia.

StatusNovel technology; limited evidence from case reports/series—considered investigational in this policy context.

Pre-procedural lumbar ultrasound

DefinitionPre-procedural lumbar ultrasound: scanning of the lumbar spine prior to neuraxial needle insertion to identify landmarks and the optimal interspace.

PurposeUsed to reduce technical failure and increase first-attempt success for neuraxial procedures, particularly in difficult spines or obese patients.

Evidence summarySystematic reviews/meta-analyses (32 trials, 3,439 patients) show increased first-attempt success (RR 1.5, NNT=5) and greater effect in difficult/obese subgroups (NNT=3).

Nerve ultrasound

DefinitionNerve ultrasound: sonographic evaluation of peripheral nerves to identify abnormalities (eg, enlargement) associated with chronic inflammatory neuropathies.

Clinical roleComplementary to nerve conduction studies to improve detection of treatment-responsive chronic inflammatory neuropathies (e.g., CIDP, MMN).

Performance dataProspective cohort data report high sensitivity (eg, 97.4%) and add diagnostic value when expertise is available.

Nerve ultrasound summary: Prospective cohort and case series indicate nerve ultrasound has high sensitivity (97.4%) and complements nerve conduction studies for detecting treatment‑responsive chronic inflammatory neuropathies; addition of nerve US increased detection of treatment‑responsive cases by ~21.1% in one cohort.evidence: cohort

Bibliographic support

Bibliographic support referenced by the policy (selected chunks for citation):

Key guideline and review references: Policy references include ACR and AIUM statements, AIUM neonatal spine practice guideline, systematic reviews and meta‑analyses on neuraxial and lumbar puncture ultrasound, RCTs, cohort studies, and multiple case series supporting neonatal imaging, pre‑procedural lumbar US, nerve ultrasound, and SonixGPS feasibility reports.