Colorado Rocky Mountain Health Plans Adult Spine Coverage

Coverage Criteria — Adult Spine Advanced Imaging

inv-01: General preconditions for advanced imaging

Covered when ALL of the following are met

Clinical evaluation prior to advanced imaging: Recent detailed history and physical examination for the current episode (or other meaningful contact when allowed) and any relevant laboratory and prior imaging studies are documented.

Includes requirement that advanced imaging should not be ordered prior to clinical evaluation; exceptions for scheduled surveillance are described in condition-specific sections.

Age-appropriate guideline applied: Individuals ≤18 years should follow Pediatric Imaging Guidelines when applicable; individuals >18 follow General Imaging Guidelines unless a condition-specific section directs otherwise.

Spine/musculoskeletal plain radiographs available: For spine and musculoskeletal indications, plain x-ray studies performed after the current episode of symptoms began or changed must be provided to the requesting provider when the guideline requires x‑rays.

Plain x‑rays are required for many condition-specific pathways unless exceptions (e.g., high-risk cervical trauma or documented ankylosing spondylitis/DISH) apply.

Repeat imaging justification: Repeat advanced imaging is appropriate only when there is evidence of disease progression, recurrence, or the repeat imaging will affect clinical management.

Serial surveillance imaging is generally not supported; see condition-specific exceptions.

inv-02: Modality and contrast criteria

Modality substitution and contrast considerations

CT in place of MRI: A CT may be approved instead of MRI when the clinical MRI criteria are met AND there is a documented contraindication to MRI (e.g., pacemaker, ICD, neurostimulator, metal implants incompatible with MRI).

When replacing MRI with CT, match the expected contrast level per guidance (e.g., MRI without contrast → CT without contrast; MRI without and with contrast → CT with contrast or CT without and with contrast).

Contrast selection guidance: Contrast use (none / with / without-and-with) must follow condition-specific guidance; unexpected need for contrast during a non-contrast study may be appropriate and justified in documentation.

CT without and with contrast is reserved for limited indications; use of iodinated contrast carries risks including CIN and should consider renal function (GFR).

Gadolinium caution: Limit use of gadolinium-based contrast agents (GBCAs) to situations where additional diagnostic information is necessary; avoid in pregnancy unless benefits outweigh risks and use caution in severe renal impairment due to NSF risk.

inv-03: Appropriate Use: 3D Rendering

Use of 3D rendering codes (CPT 76376/76377) is appropriate when ALL of the following clinical scenarios apply:

3D rendering clinical indications: Pre-operative planning for complex anatomic or surgical cases when conventional imaging is insufficient (examples: congenital skull abnormalities in infants for surgical planning; complex comminuted or displaced fractures, spine/pelvic/acetabulum fractures, complex facial fractures; other complex surgical planning scenarios).

Concurrent physician supervision/participation in the 3D reconstruction process should be documented; CPT 76376/76377 are distinct from routine 2D reformatting and should not be billed with listed incompatible modalities.

inv-04: Appropriate Use: Imaging Guidance Codes

Guidance procedure codes are appropriate when ALL of the following are met:

Guidance code appropriateness: The procedure requires real-time imaging to guide a needle or catheter (e.g., biopsy, aspiration, drainage, ablation), the imaging provided by the guidance code is necessary to accomplish the percutaneous surgical procedure, and only percutaneous surgical procedure codes are billed with the guidance code. Only one unit of a guidance code should be reported per individual encounter (date of service).

Includes CT (77011/77012/77013), MR (77021/77022), US (76942), and fluoroscopy guidance codes; CPT 77013 is restricted to non-bone ablations (bone ablations bill CPT 20982).

inv-05: Appropriate Use: CT Stereotactic Localization

When stereotactic localization CT (CPT 77011) is performed:

77011 usage: If the stereotactic localization CT is performed as a technical-only dataset that does not require radiologist interpretation, report CPT 77011; if the CT is interpreted as a diagnostic study by a radiologist, report the appropriate diagnostic CT code instead. It is not appropriate to report both the diagnostic CT code and CPT 77011 for the same session.

3D rendering should not be reported in conjunction with CPT 77011 as the procedure inherently generates a 3D dataset.

inv-06: Appropriate Use: Unlisted Procedures

Use of unlisted procedure codes is appropriate when:

Unlisted code usage: A diagnostic or interventional CT, MR, or nuclear medicine study is performed for which no appropriate anatomic site–specific CPT code exists and no applicable Category III code describes the procedure; examples include specialized navigation/planning (e.g., neurosurgical navigation datasets) or custom procedural acquisitions requiring non-standard slices/sequences.

When a Category III code exists that describes the procedure, that code should be used instead of an unlisted code (CPT 76497/76498/78999).

inv-07: Guidance imaging code coverage

Guidance imaging codes covered when used for percutaneous surgical procedures with the following constraints:

CT/MR guidance usage: Guidance codes (e.g., CPT 77013 for CT and CPT 77022 for MR) are appropriate for percutaneous surgical procedures to direct needle electrodes to tumor(s), monitor repositioning, perform multiple ablations, and confirm coagulative necrosis; CPT 77013 is limited to non-bone ablations and CT guidance for bone tumor ablation should be billed with CPT 20982.

Only one unit of any guidance code should be reported per encounter; it is inappropriate to routinely bill a separate diagnostic procedure code that duplicates the guidance imaging contained in the guidance code.

inv-08: Unlisted procedures and whole-body MRI

Unlisted CT/MR and whole-body MRI reporting rules:

Unlisted code use: Use CPT 76497 (unlisted CT) or CPT 76498 (unlisted MR) when no appropriate anatomic site–specific code exists; if a Category III code describes the procedure, that Category III code must be reported instead of an unlisted code.

Unlisted nuclear procedures use CPT 78999 when applicable.

Whole-body MRI reporting: There are no established CPT/HCPCS codes for whole‑body MRI; WBMRI should be reported using CPT 76498 only; other reporting methods such as multiple anatomic MRI codes or CPT 77084 are inappropriate.

WBMRI is generally not supported except for select cancer predisposition syndromes and certain autoimmune indications due to lack of standardization.

inv-09: Limited or follow-up CT (76380)

Limited CT (CPT 76380) is appropriate in specific limited or follow-up scenarios:

Examples of appropriate 76380 use: Limited or follow-up CT (CPT 76380) may be used for targeted slices such as limited sinus CT, limited follow-up slices through a known pulmonary nodule, or limited slices to assess a non-healing fracture; it is not indicated for treatment planning or to cover 'extra slices' of a diagnostic CT and should not be billed inappropriately with full diagnostic CT codes.

No numeric slice/sequence minimum is defined by CPT; clinical documentation should justify limited scope.

inv-10: Quantitative MR analysis coverage stance

Quantitative MR analysis CPT Category III/T codes:

Quantitative mp-MRI: Category III codes for quantitative multiparametric MR analysis (e.g., 0648T/0649T/0697T/0698T) are considered investigational/experimental for coverage purposes; volumetric/quantitative MRI brain analysis codes (0865T/0866T) are considered not medically necessary for routine clinical practice.

These procedures are primarily used in research and clinical trials; coverage is not supported for routine clinical use.

inv-11: Whole-body imaging and PET-MRI

Whole-body imaging and PET-MRI coverage conditions:

Whole-body CT stance: Whole-body CT screening for asymptomatic individuals is not indicated; limited exceptions exist for oncologic staging such as Multiple Myeloma per Oncology guidelines.

WBLow-dose CT supported only for specific oncologic indications.

Whole-body MRI stance: WBMRI is generally not supported due to lack of standardized technique and evidence of outcome benefit, except for select cancer predisposition syndromes or specific autoimmune indications where interval WBMRI may be recommended.

WBMRI should be reported using CPT 76498 when appropriate.

PET-MRI conditional coverage: PET‑MRI may be appropriate only when PET‑CT guideline criteria are met AND PET‑CT is unavailable at the treating institution AND the provider requests PET‑MRI; when allowed report using CPT 78813 (PET whole-body) + CPT 76498 (MRI unlisted).

PET‑MRI is generally not supported for most oncologic and neurologic conditions; separate PET/CT unbundling is not supported.

inv-12: Standard coverage criteria for advanced spine imaging

Advanced diagnostic imaging is covered when ALL of the following are met unless a Red Flag Indication exists:

In-person clinical evaluation: An in-person clinical evaluation for the current episode has been performed and documented, including relevant history and a detailed neurologic examination (dermatomal sensory distribution, manual motor testing, reflexes, nerve root tension signs).in-person evaluation documented

Other forms of meaningful contact are not acceptable as the in-person evaluation except where specified in condition-specific sections.

Conservative therapy trial: Clinical re-evaluation documents failure of significant clinical improvement following a recent (within 12 weeks) six‑week trial of provider‑directed conservative treatment, unless a red flag indication is present.6-week trial within prior 12 weeks

Provider-directed treatments may include NSAIDs, analgesics, corticosteroids, home exercise, physical therapy, spinal manipulation, or interventional procedures as indicated.

inv-13: Red Flag criteria

Advanced diagnostic imaging is indicated immediately for any of the following Red Flag Indications (exception to the conservative therapy requirement):

Red flags list: Any of: motor weakness; aortic aneurysm or dissection; known or suspected cancer; cauda equina syndrome; fracture; infection; severe radicular pain.N/A

Imaging of the symptomatic level is indicated and/or work-up for non-spinal sources as appropriate.

Motor weakness specifics: New onset motor weakness grade 3/5 or less in specified muscles; new onset foot drop; new onset bilateral lower extremity weakness; or progressive objective motor/sensory/deep tendon reflex deficits on clinical re-evaluation — these indicate immediate advanced imaging (MRI of relevant spinal level without contrast or without and with contrast).Grade <= 3/5 or foot drop or progressive deficits

Conservative therapy trial is waived for red flag indications.

inv-14: CT of the Spine - Indications

CT Spine indications include the following situations where CT may be approved:

When MRI contraindicated: CT (with or without contrast as appropriate) may be approved when MRI is contraindicated (e.g., implanted ferromagnetic materials or non-MRI-compatible implanted devices).

Document the MRI contraindication to justify CT substitution.

Trauma or fractures: CT without contrast, or CT without and with contrast, is appropriate for spinal trauma or fractures, especially when instability or cord/nerve compression is a concern.

CT may be used even if MRI previously performed when bony detail is required.

Neoplastic disease: CT (without or without and with contrast) is indicated for evaluation of primary or metastatic spinal neoplastic disease when indicated by clinical context.

Contrast selection per condition-specific guidance.

inv-15: CT of the Spine - Additional Indications

Spondylolysis evaluation: CT is indicated for evaluation of suspected spondylolysis when routine x‑rays are negative and/or MRI is equivocal, indeterminate or non-diagnostic.

CT without contrast often best for bony pars defects.

Calcified lesions: CT is appropriate to evaluate calcified lesions such as osteophytes or ossification of the posterior longitudinal ligament (OPLL).

inv-16: CT/Myelography - Indications and limitations

CT/Myelography is generally unnecessary as an initial study when a diagnostic quality MRI has been obtained. Indications include:

Clarify MRI findings: To clarify equivocal, indeterminate or non-diagnostic MRI findings or to further evaluate multiple spinal abnormalities.

CT/myelography reserved for situations where MRI is insufficient.

When MRI contraindicated: When MRI is contraindicated for the individual.

See CT of the Spine for examples of contraindications.

Preoperative planning: For preoperative planning (e.g., multilevel stenosis) when prior MRI is insufficient, equivocal, indeterminate or nondiagnostic.

Operating surgeon may request CT/myelography for complex planning.

Postoperative evaluation:

inv-17: Post-lumbar Discography CT

A post-lumbar discography CT is considered medically necessary following an approved discography when ALL of the following apply:

Post-discography CT requirements: A post-discography CT is coded as without contrast (CPT 72131); the discography must have been approved/performed and the post-discography CT verified as such for authorization to be issued.

Authorization will be issued for post-discography CT procedure codes only when discography already approved.

inv-18: Spinal Canal Ultrasound (CPT 76800) - Indications and Limits

Pediatric indications: Spinal canal ultrasound (CPT 76800) is generally limited to infants, newborns and young children for evaluation of CSF, suspected tethered cord, occult spinal dysraphism, spinal cord tumors, vascular malformations, or birth-related trauma.

CPT 76800 describes evaluation of the entire spine and should not be reported multiple times for different spinal regions.

Intraoperative ultrasound: Use CPT 76998 to report intraoperative spinal canal ultrasound (ultrasonic guidance); intraoperative use does not require prior authorization.

Contraindication in adult spine pain: Spinal canal ultrasound is contraindicated for assessment of adult spinal pain, radiculopathy, facet inflammation, nerve root inflammation, disc herniation, and most soft tissue conditions of the adult spine (except superficial masses).

inv-19: Lesion-specific imaging

Vertebral body hemangioma: If a vertebral body hemangioma has a typical appearance on x‑ray, no further imaging is required unless neurologic symptoms/signs are present; atypical appearance or neurologic features warrant MRI without and with contrast, and CT without contrast if MRI equivocal.

No routine follow-up imaging once diagnosis established without neurologic features.

Tarlov cysts: Incidental Tarlov cysts may be further evaluated with MRI lumbar spine without and with contrast (CPT 72158) or CT/myelography (CPT 72132) when clinically indicated.

Clinical correlation required as most are incidental.

Other spinal lesions: MRI without and with contrast or CT without contrast is indicated when lesions are seen on x‑ray or non‑contrast MRI and further characterization or surgical planning is recommended by a spine specialist or radiologist.

inv-20: MRA Spinal Canal and Angiography

MRA Spine is infrequently utilized. Indications include suspected spinal AVM/AVF and selected preoperative planning or subarachnoid hemorrhage scenarios.

Suspected spinal AVM/AVF: Initial study for suspected spinal arteriovenous malformation/fistula should be MRI spine without and with contrast; if suspicion remains high, catheter angiography (CPT 72159 or 70496) is recommended.

MRA may help identify feeder vessels but catheter angiography is more definitive.

Subarachnoid hemorrhage without identified brain aneurysm: When SAH occurs without an identified intracranial aneurysm, catheter angiography is the definitive study to evaluate for a possible spinal source; MRA may have a limited role in selected cases.

inv-21: PET/CT and Cone-beam CT stance

Spine PET/CT is considered not medically necessary for routine assessment of spinal disorders other than neoplastic disease due to inadequate evidence.

Consider PET/CT only for oncologic indications per Oncology guidelines.

Cone-beam CT cervical: Cone‑beam CT for imaging of the cervical spine is considered not medically necessary for routine assessment outside the operative setting.

inv-22: Neck (Cervical Spine) Pain Imaging Criteria

Advanced imaging for neck (cervical spine) pain (with or without neurologic features) is covered when ALL of the following are met:

Cervical advanced imaging prerequisites: 1) An in‑person clinical evaluation for the current episode (initial or re‑evaluation). 2) Failure of a recent (within 12 weeks) six‑week trial of provider‑directed treatment unless a red flag is present. 3) Clinical re‑evaluation after the treatment period (in‑person or other meaningful contact).

Preferred advanced imaging: MRI cervical spine without contrast (CPT 72141); CT cervical (CPT 72125) or CT myelography (CPT 72126) if MRI contraindicated.

inv-23: Neck (Cervical Spine) Trauma Imaging Criteria

Advanced imaging for cervical spine trauma is covered when ALL of the following are met:

Cervical trauma imaging prerequisites: 1) An in‑person clinical evaluation for the current episode. 2) Failure of a recent (within 12 weeks) six‑week trial of provider‑directed treatment unless a red flag is present. 3) Clinical re‑evaluation after the treatment period. 4) Results of plain x‑rays of the cervical spine performed after the current episode are available to the requesting provider (not required for high‑risk mechanisms).

For individuals with ankylosing spondylitis or DISH, plain x‑rays and the six‑week trial/re‑evaluation are NOT required and whole‑spine MRI/CT can be approved.

inv-24: Thoracic spine pain (atraumatic) — advanced imaging

All of the following are required prior to advanced imaging:

Prerequisites: 1) An in‑person clinical evaluation for the current episode (initial or re‑evaluation). 2) Failure of a recent (within 12 weeks) six‑week trial of provider‑directed treatment unless a red flag is present. 3) Clinical re‑evaluation after the treatment period (in‑person or other meaningful contact).

If MRI is contraindicated, CT thoracic without contrast (CPT 72128) or CT myelography (CPT 72129) may be used as alternatives to MRI (CPT 72146).

inv-25: Thoracic spine trauma — advanced imaging

All of the following are required prior to advanced imaging:

Prerequisites: 1) An in‑person clinical evaluation for the current episode. 2) Failure of a recent (within 12 weeks) six‑week trial of provider‑directed treatment unless a red flag is present. 3) Clinical re‑evaluation after the treatment period. 4) Results of plain x‑rays of the thoracic spine performed after the current episode of symptoms started or changed must be available to the requesting provider.

For ankylosing spondylitis or DISH, plain x‑rays and the six‑week trial/clinical evaluation are NOT required and whole‑spine MRI/CT can be approved.

inv-26: Lumbar spine pain (atraumatic) — advanced imaging

All of the following are required prior to advanced imaging:

If MRI contraindicated, CT lumbar without contrast (CPT 72131) or CT myelography (CPT 72132) is indicated as an alternative to MRI (CPT 72148).

inv-27: Coccydynia without neurological features — advanced imaging

All of the following are required prior to advanced imaging:

Prerequisites: 1) An in‑person clinical evaluation for the current episode. 2) Failure of a recent (within 12 weeks) six‑week trial of provider‑directed treatment unless a red flag is present. 3) Clinical re‑evaluation after the treatment period. 4) Plain x‑rays of the sacrum/coccyx are negative for fracture.

Preferred modality: MRI pelvis without contrast (CPT 72195); CT pelvis without contrast (CPT 72192) if MRI contraindicated.

inv-28: Lower extremity pain with neurological features (radiculopathy)

Lumbar radiculopathy / lower extremity pain with neurological features — advanced imaging is covered when ALL of the following are met:

Required prior to advanced imaging: 1) An in‑person clinical evaluation for the current episode. 2) Failure of a recent (within 12 weeks) six‑week trial of provider‑directed treatment unless a red flag is present. 3) Clinical re‑evaluation after the treatment period.6 weeks

Indicated advanced studies include MRI lumbar without contrast (CPT 72148) or CT lumbar without contrast (CPT 72131) or CT myelography (CPT 72132) when MRI contraindicated or per surgical planning.

inv-29: Low back (lumbar) trauma

Low back (lumbar spine) trauma — advanced imaging is covered when ALL of the following are met:

Required prior to advanced imaging for lumbar trauma: 1) An in‑person clinical evaluation for the current episode. 2) Failure of a recent (within 12 weeks) six‑week trial of provider‑directed treatment unless a red flag is present. 3) Clinical re‑evaluation after the treatment period. 4) Results of plain x‑rays of the lumbar spine performed after the current episode of symptoms started or changed must be available to the requesting provider. 5) Definitions of radiculopathy per guidelines referenced.6 weeks

For individuals with ankylosing spondylitis or DISH, whole‑spine MRI and CT can be approved without x‑rays or a six‑week trial.

inv-30: Myelopathy

Myelopathy — advanced imaging is covered when ANY of the following are present:

Indications for MRI in myelopathy: Documented or reasonably suspected myelopathy; post‑traumatic syrinx with increased spinal pain or worsening neurological symptoms; sustained unexplained Lhermitte's sign; unexplained Babinski or Hoffmann's signs; unexplained hyperreflexia; unexplained bilateral motor weakness.

Conservative therapy is not required for suspected myelopathy and plain x‑rays are not required regardless of prior surgery or trauma. Preferred modality: MRI cervical and thoracic spine without contrast (or without and with contrast as indicated).

inv-31: CT/myelography alternatives

Alternate or adjunct imaging options:

Non-MRI imaging: CT without contrast or CT with myelography may be considered as an alternative to MRI when MRI is contraindicated, or as an adjunct to MRI for surgical planning.

CT/myelography may better demonstrate bony encroachment; MRI is superior for intramedullary cord evaluation.

inv-32: Myelopathy

Imaging choices for suspected myelopathy

Modality preference: MRI is the preferred imaging modality for evaluation of myelopathy because of superior soft tissue definition and ability to visualize intramedullary cord signal changes.

CT use cases: CT without contrast or CT myelography can be considered when MRI is contraindicated or in addition to MRI for surgical planning; CT is better for bony encroachment assessment.

inv-33: Spondylolysis

When advanced imaging is indicated for suspected spondylolysis

Preconditions: Results of plain x‑rays performed after the current episode of symptoms started or changed need to be available to the requesting provider unless pediatric guidance applies.

Indications for advanced imaging: High clinical suspicion with negative plain x‑rays; negative SPECT prompting MRI or CT; lesion seen on SPECT requiring CT; documented need for preoperative planning; or failure of a six‑week trial of provider‑directed conservative treatment with clinical re‑evaluation.6 weeks

Appropriate studies include SPECT/SPECT‑CT, MRI lumbar without contrast (CPT 72148) or CT lumbar without contrast (CPT 72131) depending on context.

Pediatric note: Refer to pediatric-specific spondylolysis guidance; repeat advanced imaging is not medically necessary for an established well‑defined non‑healing pars defect as bony healing cannot be achieved non‑surgically.

inv-34: Spondylolisthesis and Lumbar Spinal Stenosis

Advanced imaging indications after plain radiographs

Preconditions: Results of plain x‑rays performed after the current episode of symptoms started or changed need to be available to the requesting provider.

Indications for imaging: Failure of a six‑week trial of provider‑directed treatment with clinical re‑evaluation; preoperative evaluation; or presence of red flag indications.6 weeks

MRI lumbar without contrast (CPT 72148) or CT lumbar without contrast (CPT 72131) are indicated; CT/myelogram (CPT 72132) may be used for surgical planning, especially for multilevel stenosis.

Severe symptom exception: Severe neurogenic claudication substantially restricting activity or requiring frequent narcotic analgesics may justify expedited imaging without further delay beyond clinical judgment.

inv-35: SI Joint Imaging

Sacro-Iliac (SI) Joint Pain/Sacroiliitis — advanced imaging is indicated when:

SI Joint advanced imaging indications: CT pelvis without contrast (CPT 72192) or MRI pelvis without contrast (CPT 72195) is indicated when initial plain x‑rays are equivocal or nondiagnostic AND failure of six weeks of provider‑directed treatment with clinical re‑evaluation; OR any one of: sacral or SI joint fractures, red flag indications, preoperative planning, or suspicion of neoplastic/inflammatory/infectious disease (MRI pelvis without and with contrast CPT 72197 when indicated; CT pelvis CPT 72192 if MRI contraindicated).6 weeks for conservative therapy when required

MRI pelvis with/without contrast is preferred for pediatric JIA and certain inflammatory indications.

inv-36: Inflammatory Spondylitis Imaging

Inflammatory Spondylitis — imaging recommendations

Initial imaging: If plain x‑rays are equivocal or not diagnostic, MRI (without and with contrast or without contrast) of the affected spinal region is indicated; CT without contrast if MRI contraindicated.

Follow-up imaging: For follow‑up of treatment response or disease progression, options include combinations of MRI sacroiliac joints (MRI pelvis) with or without contrast and MRI spine area of interest per findings; plain x‑rays showing no progression may alter imaging choice.

Trauma with ankylosing spondylitis/DISH: In documented ankylosing spondylitis or DISH with spine pain after trauma, plain x‑rays are not required prior to advanced imaging.

inv-37: Spinal Compression Fracture Imaging

Spinal Compression Fractures — imaging indicated after plain x‑ray when the location of pain is concordant:

Compression fracture indications (no malignancy): MRI without contrast, CT without contrast, whole body bone scan (CPT 78306), SPECT (CPT 78803) or SPECT/CT (CPT 78830) of the affected spinal region is indicated after plain x‑ray and concordant pain for any one of: new radiographic compression fracture; nondiagnostic x‑rays with severe persistent pain (>1 week) in predisposed individuals; indeterminate fracture acuity on x‑ray; or preoperative planning for vertebral augmentation procedures.

inv-38: Syringomyelia: Initial and Follow‑up Imaging

Imaging for suspected syringomyelia and follow‑up is covered when the following criteria are met:

Initial evaluation for suspected syringomyelia: MRI cervical and/or thoracic spine (without contrast or without and with contrast; CPT 72141/72156 and 72146/72157) is indicated when syringomyelia is suspected.

After identification of a syrinx: If a syrinx is identified, obtain MRI brain without contrast (CPT 70551) to evaluate for syringobulbia and complete MRI cervical, thoracic, and lumbar spine as needed to define extent or identify skip lesions.

Follow‑up imaging for syringomyelia: Follow‑up MRI (cervical, thoracic, brain as involved) is indicated; perform annual imaging until non‑progression is established, then advanced imaging every three years for life; repeat earlier if neurologic deterioration or post‑surgical changes warrant.Annual until non‑progression; then every 3 years

If concern for malignancy, perform imaging without and with contrast.

inv-39: Spinal Deformities Imaging

Imaging for spinal deformity (scoliosis/kyphosis):

Prerequisite: Plain x‑rays (e.g., Cobb radiographs) of the affected spinal regions must have been performed and results available to the requesting provider prior to advanced imaging.

Indications for advanced imaging: MRI (without or without and with contrast) or CT/myelography if MRI contraindicated is indicated for preoperative evaluation; congenital or atypical curves that may be associated with cord pathology; associated neurologic signs/symptoms; and thoracic curves with convex left configuration.

CT for complex osseous deformity: CT of the affected spinal regions (contrast as requested) is indicated in cases with complex osseous deformity for preoperative evaluation; CTA/MRA are not indicated for initial anterior spinal surgery preoperative planning.

inv-40: Post‑operative Spine Imaging

Post‑operative spine imaging:

>6 months post‑op imaging: For individuals more than six months post‑operative, following availability of plain post‑operative x‑rays, MRI (without and with contrast) or CT (without contrast) of the affected region is indicated when there is no significant improvement after a recent (within 12 weeks) six‑week trial of provider‑directed treatment with clinical re‑evaluation OR if red flag indications are present.>6 months post‑op plus failed conservative trial or red flags

Consider nuclear medicine when MRI/CT are nondiagnostic for suspected failed fusion.

<=6 months with prolonged intractable pain: If within six months post‑op and there are residual, new, recurrent, or worsening symptoms related to the surgical site, MRI without and with contrast is indicated; if MRI contraindicated, CT without contrast or CT with myelography is indicated.<=6 months with intractable/worsening symptoms

Routine post‑fusion:

inv-41: Routine Post-Fusion Imaging

Routine post-fusion imaging

Routine post-fusion imaging: Following a clinically successful spinal fusion, advanced diagnostic imaging is generally not indicated.

PET is not indicated for routine assessment of spinal fusions or unsuccessful spine surgery.

inv-42: Imaging for Prolonged Intractable Postoperative Pain

Prolonged intractable pain within six months of spinal surgery

Indications for MRI post-surgery: After plain post‑operative x‑rays are available to the requesting provider, MRI without and with contrast of the affected spinal region(s) is indicated if there are residual, new, recurrent, or worsening symptoms related to the surgical site within six months post‑op; if MRI contraindicated, CT without contrast or CT with myelography is indicated.postoperative within 6 months

inv-43: Revision Anterior Fusion Surgery — Preoperative Vascular Imaging

Revision anterior fusion preoperative planning

Preoperative vascular imaging options: If requested by the operating surgeon for revision thoracic or lumbar anterior spinal arthrodesis, CTA pelvis (CPT 72191) and/or CTA abdomen (CPT 74175) OR MRA pelvis (CPT 72198) and/or MRA abdomen (CPT 74185) are indicated for preoperative vascular planning.

CTA/MRA generally not indicated for initial anterior spinal surgery preoperative planning unless abnormal vasculature is known or anticipated.

inv-44: Preprocedure Imaging Requirements

Imaging prior to spine procedures

Advanced imaging for surgical planning: Advanced imaging needed for surgical planning should have been performed within the past six months when criteria for advanced imaging studies are met.<= 6 months

MRI/CT modalities per specific spine guidelines.

Imaging prior to interventional injections: Advanced imaging is not required prior to facet injections, medial branch blocks, or RF ablation unless clinical criteria are met. Advanced imaging of cervical/thoracic spine is required within 24 months prior to interlaminar or transforaminal epidural steroid injections when criteria are met; lumbar transforaminal injections require advanced imaging when criteria met; lumbar interlaminar/caudal injections do not require imaging unless criteria are met.<= 24 months for specific injections

For symptomatic spinal stenosis an initial trial of injection requires MRI/CT within 24 months and failure of ≥4 weeks conservative therapy plus significant functional limitations.

inv-45: SCS and Vertebral Augmentation Imaging

Spinal cord stimulator and vertebral augmentation

SCS planning: MRI thoracic spine without contrast (CPT 72146) is generally the study of choice prior to SCS placement; CT thoracic spine without contrast (CPT 72128) or CT/myelography (CPT 72129) are acceptable alternatives. Imaging of the lumbar spine is not indicated for SCS placement or removal.

Post-vertebral augmentation imaging: CT without contrast of the affected spinal region within 24 hours post‑procedure is indicated to evaluate for neurologic sequelae from cement extravasation.<= 24 hours

inv-46: Nuclear Medicine Spine Imaging Criteria

Nuclear medicine indications for spine

Implant loosening or failed fusion: When recent plain x‑ray is nondiagnostic, bone scan (CPT 78315) OR SPECT (CPT 78803/78831) OR SPECT/CT (CPT 78830/78832) are indicated for suspected implant loosening or failed fusion with suspected pseudoarthrosis (MRI may be limited by metal artifact).

Osteomyelitis evaluation: Initial evaluation of suspected osteomyelitis: bone scan (CPT 78300/78305/78306/78315) OR SPECT (CPT 78803) OR nuclear bone marrow imaging (CPT 78102/78103/78104) OR radiopharmaceutical inflammatory imaging (CPT 78800-78803) as appropriate.

Follow-up imaging modality and timing depend on disease and prior imaging.

Facet arthropathy and spondylolysis: Radiopharmaceutical inflammatory imaging or SPECT/SPECT‑CT may be used to evaluate facet arthropathy; SPECT is the reference standard for radiographically occult active spondylolysis in young patients.

Bone scan/SPECT not routinely used for initial uncomplicated low back pain.

inv-47: Covered Nuclear Medicine Indications

Covered when ONE of the following indications applies (study selection as listed):

Osteomyelitis follow-up: Follow-up imaging to evaluate response to treatment in established osteomyelitis using bone scan (78300/78305/78306/78315) OR nuclear bone marrow imaging (78102/78103/78104), with timing based on disease and prior imaging.

Facet arthropathy evaluation: Evaluation of facet arthropathy using radiopharmaceutical localization inflammatory imaging (78800–78803) OR SPECT (78803) OR SPECT/CT (78830) as clinically appropriate.

Suspected spondylolysis: Evaluation of suspected spondylolysis in patients with radiographically occult lesions using SPECT (78803/78831) or SPECT/CT (78830/78832); SPECT is the reference standard in young patients.

New symptomatic compression fracture without known malignancy: For new symptomatic compression fracture identified on radiographs or CT with no known malignancy consider whole body bone scan with add‑on SPECT (78803) or SPECT/CT (78830) to assess acuity.

Studies, treatments, procedures, or devices are considered investigational/experimental when there is a paucity of supporting evidence, the evidence has not matured to demonstrate improved health outcomes, clinical utility has not been shown, or there is no collective professional support. Supporting evidence means credible peer‑reviewed literature (e.g., well‑conducted randomized trials or adequately powered cohort studies) or recognized specialty‑society recommendations; absence of such evidence places the service in the investigational/experimental category and it is not supported for coverage.

Advanced imaging is generally unnecessary for patients whose spinal pain and/or radiculopathy have resolved or are clearly improving. Similarly, for persons with stable, longstanding spinal pain without new neurologic findings or clinically significant change on exam, routine advanced imaging is not indicated because it typically does not alter management or improve outcomes.

For initial preoperative planning of an anterior spinal fusion, CTA or MRA of the relevant vascular territories is not medically necessary as a routine study. CTA/MRA may be considered only in specific revision or surgeon‑requested scenarios (see surgical planning/revision guidance); routine use before initial anterior spine surgery is not supported.

Routine use of PET for assessment of spinal fusion integrity or evaluation after unsuccessful spine surgery is not indicated. Nuclear modalities (including PET/CT) are generally reserved for suspected neoplastic disease or other specific indications; they are not supported as first‑line testing for uncomplicated low back pain or routine post‑fusion surveillance.

Covered Indications by Condition and Modality

Coding — CPT/HCPCS Groups and Unit Rules

Unit of service rule

Provider Actions — Prior Authorization, Documentation, Denial Risks

Prior Authorization

Medical necessity review under Ohio code

This Medical Policy applies to the state of Ohio. Requests for services described as unproven or subject to coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01. Providers requesting such services should anticipate a medical necessity review under Ohio code and submit complete supporting documentation.

Requests for services stated as unproven will be reviewed for medical necessity per Ohio Administrative Code 5160-1-01.
Complete clinical documentation is required to support medical necessity determinations under Ohio rules.

Documentation Required

Prior clinical evaluation required

Advanced imaging should not be ordered prior to a pertinent clinical evaluation by the treating physician. The evaluation must include a relevant history and focused physical examination performed in-person for the current episode of symptoms unless the guideline for the specific condition allows other meaningful contact. Requests lacking documentation of an in-person clinical evaluation (when required) may be denied.

Frequency Limits and Follow-up Intervals

inv-257: MRI (with GBCA) — Assess necessity for repetitive GBCA-enhanced MRIs; limit and justify repetitive use

GBCA repetition cautionAssess necessity for repetitive gadolinium-based contrast agent (GBCA) enhanced MRIs; limit and justify repeat GBCA studies because FDA recommends restricting GBCA use to situations where additional information is necessary.

Contrast use principleAppropriate levels of contrast (none / with / without and with) are determined by condition-specific guidance and the clinical question.

When to substitute modalityConsider CT if MRI is contraindicated; match contrast level per condition-specific rules when substituting modalities.

inv-258: PET-MRI — PET-MRI reporting and frequency considerations

PET‑MRI conditional reportingPET‑MRI may be used only when PET‑CT guideline criteria are met AND PET‑CT is unavailable at the treating institution and the provider requests PET‑MRI; when allowed report as PET whole-body (CPT 78813) + MRI unlisted (CPT 76498).

Prior Authorization Expectations

Note

Contrast Selection and Gadolinium Guidance

Note

Not Covered / Not Medically Necessary

PET/MRI is generally not supported as a routine modality and may only be considered when PET‑CT criteria are met and PET‑CT is unavailable and the provider specifically requests PET‑MRI; in such cases reporting using CPT 78813 plus an appropriate unlisted MRI code is the documented pathway. In addition, do not bill CPT 76376/76377 (3D rendering) in conjunction with modalities/procedures explicitly listed as disallowed (for example CAD, MRA, CTA, PET/CT, SPECT), unless policy exceptions apply and documentation supports concurrent physician supervision of the reconstruction.

Advanced diagnostic imaging is not indicated for stable, longstanding spinal pain in patients without new or progressive neurologic findings or without clinically meaningful changes in symptoms or physical examination; such imaging rarely changes management and is discouraged.

Cone‑beam CT for routine cervical spine assessment outside the operative setting is considered not medically necessary. Evidence does not support its routine use for non‑operative evaluation of the cervical spine.

Advanced diagnostic imaging is not supported for the evaluation or management of fibromyalgia. The scientific evidence does not justify routine use of CT, MRI, or other advanced modalities for this condition.

CTA or MRA is not medically necessary for preoperative planning for an initial anterior spinal surgery. Likewise, routine PET for assessment of spinal fusions or for routine evaluation after unsuccessful spine surgery is not indicated and should not be used as standard postoperative surveillance.

Routine PET for assessing spinal fusion status or for evaluation after unsuccessful spine surgery is not indicated. Nuclear medicine studies such as bone scan, SPECT, or SPECT/CT have specific, limited indications (e.g., suspected implant loosening, occult fracture, or infection) and are not supported as routine initial studies for uncomplicated low back pain or routine post‑fusion surveillance.

Definitions and Clinical Terms

inv-199: Guidelines — Evidence-based clinical guidelines

Evidence-based guidelinesThese are evidence-based clinical guidelines developed from peer-reviewed literature, specialty society recommendations, and expert input to guide appropriate imaging selection.

Investigational / Experimental definitionInvestigational/experimental denotes lacking sufficient supporting evidence, demonstrated clinical utility, or collective professional support; such services are considered not supported.

Clinical judgment noteGuidelines are intended to guide but do not replace clinician judgment; physician discretion may override guidelines when clinically appropriate and documented.

inv-200: Investigational / Experimental — Lacking sufficient evidence or clinical utility

Investigational / Experimental stanceProcedures or studies lacking sufficient evidence, mature outcomes data, or collective support are considered investigational/experimental and not supported.

Background and Scope

These guidelines synthesize evidence‑based recommendations across modalities to guide appropriate use of advanced imaging of the adult spine. They emphasize that advanced studies (CT, MRI, PET, SPECT, ultrasound) should be ordered when supported by documented clinical evaluation, relevant plain radiographs, and when imaging will affect management. The guidance is derived from major society criteria and peer‑reviewed literature and is intended to support medical necessity determinations and utilization review.

OpenPayer

Adult Spine Imaging Guidelines (For Ohio Only)

Coverage Criteria — Adult Spine Advanced Imaging

Covered Indications by Condition and Modality

Coding — CPT/HCPCS Groups and Unit Rules

Provider Actions — Prior Authorization, Documentation, Denial Risks

Frequency Limits and Follow-up Intervals

Prior Authorization Expectations

Contrast Selection and Gadolinium Guidance

Not Covered / Not Medically Necessary

Definitions and Clinical Terms

Background and Scope