CurrentCapital BluecrossPolicy MP 5.051

Dynamic Spinal Visualization and Vertebral Motion Analysis

Defines Capital BlueCross coverage stance for dynamic spinal visualization technologies (digital motion x-ray, videofluoroscopy/cineradiography, dynamic MRI) and vertebral motion analysis for evaluation of neck and back pain; applies to applicable Capital BlueCross products and programs.

Policy Summary

PayerCapital Bluecross

PolicyDynamic Spinal Visualization and Vertebral Motion Analysis

Policy CodePolicy MP 5.051

Change TypeNo material change

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionDo not submit prior authorization to override investigational/non-covered status; verify member benefits and eligibility before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MP 5.051Policy identifier

2Investigational codes listed

12+References cited

2012KineGraph VMA 510(k) year

Coverage Determination

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.

Investigational / Not covered

Covered when ALL of the following are met

Investigational stance: The use of dynamic spinal visualization is considered investigational; vertebral motion analysis is considered investigational.

Insufficient evidence to conclude improvement in net health outcome; see Summary of Evidence reporting limited sensitivity and lack of evidence for improvement in symptoms or function.

Coverage implication: Services identified as investigational (dynamic spinal visualization and vertebral motion analysis) are not covered.

Procedures reported with CPT codes 76120 and 76125 are designated investigational and therefore not covered.

The use of dynamic spinal visualization techniques (including digital motion x-ray, videofluoroscopy/cineradiography, and dynamic MRI) and vertebral motion analysis is considered investigational and is not covered. There is insufficient evidence to conclude these services improve net health outcomes. This policy applies to applicable Capital BlueCross products and programs and identifies specific procedure codes associated with these investigational services.

Procedures billed with CPT codes 76120 and 76125 are designated investigational and are therefore not covered under this policy.

Provider Actions and Billing Considerations

Prior Authorization

Prior Authorization / Coverage Stance

Prior authorization / coverage stance: Dynamic spinal visualization and vertebral motion analysis are considered investigational and are not covered by Capital BlueCross. Prior authorization does not make investigational services covered.

These services are investigational and not covered under Capital BlueCross policies.
Prior authorization requests for these investigational services will not change coverage determination.

Note

Coding and Coverage Implication

Code listing and coverage implication: The codes listed in the coding section are for informational purposes only. Identification of a code does not indicate coverage — coverage depends on the member's benefit plan and contract.

Code identification in this policy does not denote coverage.
Coverage determinations must be made based on the member's benefit information and contract terms.

Denial Risk

Investigational Procedure Codes

Investigational procedure codes — potential denial risk: Use of the following procedure codes for dynamic spinal visualization or vertebral motion analysis may result in claim denial because these services are investigational and not covered.

Procedure Codes: 76120, 76125
Claims billed with these codes for the investigational services may be denied.

Note

Relation to Standard Flexion/Extension Radiography

Relation to standard flexion/extension radiography: Flexion/extension radiographs are the conventional comparator and diagnostic standard for assessing intervertebral movement and spinal instability. Dynamic spinal visualization and vertebral motion analysis are being evaluated as alternatives but remain investigational.

Flexion/extension radiographs are the standard diagnostic comparator for spinal instability assessment.

Documentation Required

Coverage Verification and Claim Processing

Coverage verification and claim processing: Providers must verify member eligibility, benefits, and contract terms with Capital Blue Cross prior to providing services. Payment is subject to benefit coverage, medical necessity, and final claim adjudication according to the member's contract.

Verify member benefits and eligibility with Capital Blue Cross before rendering services.
Final claim processing is based on the member's benefit program, medical necessity, and contract terms.

Note

Coding and Coverage Note

Coding and coverage note: Reiterating: listing a code is not a determination of coverage. Providers should confirm coverage via member benefit information and contact Provider Services or Member Services with questions.

Code lists are informational; coverage depends on member-specific benefits.
Contact Capital Blue Cross Provider Services or Member Services for coverage questions.

Definitions of Technologies

Definition

TermDigital Motion X-Ray

DefinitionSequential digitized x-ray snapshots or computer-based x-ray images displayed as a moving image to evaluate intervertebral motion.

NotesUses x-rays to create images on film, video monitor, or computer screen; results can be reviewed by a physician or with computer software.

Definition

TermVideofluoroscopy / Cineradiography

DefinitionFluoroscopy-based real-time video imaging that creates motion pictures of internal structures; images may be displayed live and/or recorded for later computer analysis or review.

NotesAlso called cineradiography; results can be evaluated by a physician alone or with assistance of computer software.

Definition

TermDynamic MRI

DefinitionMRI performed using an MRI-compatible stepless motorized positioning device with real-time sequences to provide passive kinematic imaging of the cervical spine during flexion and extension.

NotesImage quality is lower than typical MRI sequences but may show changes in vertebral alignment, spinal canal width, and spinal cord; higher-resolution imaging can be performed at end positions of flexion/extension.

Definition

TermVertebral Motion Analysis (VMA)

DefinitionSystems (e.g., KineGraph VMA) that provide assisted bending with fluoroscopic imaging and computerized analysis, using automated tracking (facial/vertebral recognition) to quantify vertebral movement across an image series.

NotesDesigned to reduce patient-driven variability in bending and assess motion across the entire imaging series; some systems were cleared by FDA (KineGraph VMA cleared 2012).

OpenPayer

Dynamic Spinal Visualization and Vertebral Motion Analysis

Coverage Determination

Coding and Procedure Codes

Provider Actions and Billing Considerations

Background and Clinical Context

Definitions of Technologies

76120	Procedure code listed in policy as investigational; therefore not covered
76125	Procedure code listed in policy as investigational; therefore not covered