CPT inclusion does not imply PA

The inclusion of CPT codes in this guideline does not mean the code is managed or requires prior authorization; providers must follow payer-specific prior authorization policies for the member’s benefit.

Submit adequate clinical evaluation for PA

Obtain and submit adequate clinical information to UnitedHealthcare to establish medical necessity before requesting advanced imaging; do not order advanced imaging prior to a pertinent clinical evaluation by the treating physician or specialist.

• Include pertinent clinical evaluation since onset or change in symptoms (detailed history, physical/neurologic exam, labs, prior imaging).
• Ensure plain x-rays from when the current episode started/changed are available when required by the spine guidelines.

PA may be required for CPT 76376/76377

Verify prior authorization requirements for 3D rendering codes CPT 76376 and CPT 76377; authorization may be required even when the base imaging study does not need prior authorization.

• Document concurrent physician supervision/participation per guideline when billing 76376/76377.
• Do not use 76376/76377 for routine 2D reformatting.

PET/MRI requires condition-specific justification and PA

Use PET/MRI only when condition-specific PET/MRI criteria are met or when PET/CT criteria are met and PET/CT is unavailable; report PET/MRI using CPT 78813 plus CPT 76498 when permitted.

• PET/MRI is generally not medically necessary except per listed criteria.
• If used in lieu of PET/CT, ensure provider requests PET/MRI and document that PET/CT is unavailable.

Use correct CPTs for authorization and billing

Use the specified spine procedure CPT codes when requesting authorization and billing; prior authorization processes apply per member benefit for the listed pediatric spine imaging codes.

• Include appropriate CPTs for MRI (e.g., 72141/72146/72148 and 72156/72157/72158) and relevant nuclear/ultrasound codes as listed when submitting requests.
• Follow standard prior authorization processes for the listed procedure codes.

Coding: intraoperative ultrasound and 76800 use

For intraoperative spinal canal ultrasound use CPT 76998 (intraoperative ultrasonic guidance); do not report CPT 76800 multiple times for different spinal canal areas in a single operative event.

• CPT 76998 is appropriate for intraoperative ultrasound guidance.
• CPT 76800 should not be used repeatedly to represent imaging of different spinal canal segments.

Justify advanced imaging with exam and x-rays

Before seeking advanced imaging approval, document a pertinent clinical evaluation since onset or change in symptoms and prior plain radiographs when required; advanced imaging should be justified by the guideline criteria.

• Include detailed history and a thorough neurologic exam.
• Provide plain x-rays performed after the current episode started/changed to support the request.

Order imaging consistent with guideline indications

Ensure the requested imaging matches guideline indications: spinal ultrasound (CPT 76800) for infants ≤6 months, and MRI spine CPTs (72141/72146/72148; 72156/72157/72158) only when age‑ and indication‑based criteria are met.

• Spinal ultrasound is generally appropriate up to 6 months; MRI is indicated for older infants or abnormal findings.
• Order modality per the specific condition-based indications in the guideline.

Specialist-ordered MRI required for preop planning

MRI of the entire spine is medically necessary for preoperative planning only when ordered by an appropriate specialist; request MRI after specialist consultation and document the specialist’s involvement.

• Document that a specialist ordered or consulted for the preoperative MRI.
• Provide clinical indications that support whole-spine MRI for surgical planning.

Obtain PA with clinical justification per plan rules

Obtain prior authorization when the member’s benefit requires it and document clinical indications supporting the selected CPT(s); many listed modalities and CPTs are medically necessary only in defined situations and require justification per plan rules.

• Document how the imaging result will impact management.
• Follow member benefit/prior authorization rules for the CPTs billed.

Prefer step-down imaging and avoid unnecessary repeats

Consider less invasive or lower-cost imaging options before ordering advanced imaging; repeat imaging is not generally necessary unless there is evidence of progression or it will change management.

• Review prior diagnostic tests and imaging history before ordering additional studies.
• Reserve repeat imaging for documented progression, recurrence, or management impact.

Include clinical evaluation since symptom onset in documentation

Include a pertinent clinical evaluation in the prior authorization submission that documents onset or change in symptoms, detailed history, and a thorough neurologic exam as required to establish medical necessity for advanced imaging.

• Specify relevant labs and prior imaging studies that support the request.
• State how the imaging result will affect treatment decisions.

Require 4‑week conservative care trial for age ≥6 without red flags

For children age 6 and older without red flags, document and complete a 4‑week trial of provider‑supervised conservative treatment before advanced imaging will be approved.

• Document start and duration of the conservative treatment trial.
• If 'red flag' findings are present, advanced imaging may be approved earlier per guideline.

Use plain radiography first for scoliosis evaluation

For evaluation of scoliosis, obtain standing PA and lateral plain radiographs as the initial studies and use them for follow-up; advanced modalities are for preoperative planning or when x‑rays are inconclusive.

• Provide standing PA and lateral x-rays with the request.
• If MRI/CT is requested, document specific findings or surgical planning needs not addressed by x-rays.

Prefer spinal ultrasound in infants ≤6 months; escalate if abnormal

For infants ≤6 months, prefer spinal ultrasound (CPT 76800) as the initial modality; if ultrasound is abnormal or indeterminate, or the infant is older than 6 months, obtain MRI per guideline indications.

• If conus position is uncertain in premature infants, repeat spinal ultrasound in 4–6 weeks.
• Do not perform routine follow-up ultrasound after a normal screening ultrasound.

Ultrasound-first in young infants; MRI if indicated or after specialist input

Spinal ultrasound (CPT 76800) is initial preferred modality in infants up to 6 months; MRI may be approved without prior ultrasound if symptoms, exam, or specialist consultation indicate earlier MRI.

• Document age and whether ultrasound was performed and its findings when requesting MRI.
• If specialist ordered MRI, include documentation of the specialist consultation.

CPT inclusion note — confirm payer PA rules

Inclusion of a CPT code in the guideline does not imply it requires prior authorization; verify payer-specific prior authorization requirements before billing.

Required clinical documentation for PA submissions

Submit required clinical documentation with PA requests: detailed history, neurologic exam, documentation of conservative treatment duration when applicable, and prior plain radiographs performed after symptom onset or change.

• Include documentation that prior imaging and exams are expected to affect management.
• Provide dates and results of prior plain x-rays when required by the guideline.

Document concurrent supervision for 3D rendering codes

When requesting CPT 76376 or 76377, document the physician’s concurrent supervision/participation including the anatomic region selected, tissue/structure types to display, and images or cine loops archived to support the 3D rendering claim.

• Record the physician’s design decisions and monitoring/adjustments of the 3D work product.
• Archive and make available the images/cine loops and documentation of supervision.

Use CPT 76140 for outside exam interpretation

When an outside exam is being interpreted and a secondary interpretation is requested, report CPT 76140 rather than diagnostic imaging codes for the previously performed exam.

• Use CPT 76140 for interpretation of outside studies.
• Do not bill diagnostic imaging codes for interpretation of exams performed elsewhere.

Include history, neurologic exam, and conservative care details

Clinical documentation submitted with advanced imaging requests should include detailed history, a thorough neurologic exam, and documentation of conservative treatment duration when applicable to support medical necessity.

• Explicitly state duration and content of conservative management when required (e.g., 4‑week trial for age ≥6 without red flags).
• Ensure neurologic exam findings and rationale for imaging are described.

Document specialist consultation for multi-level or preop imaging

When ordering imaging for other spinal levels or for preoperative planning, include documentation of ordering by or consultation with an appropriate specialist.

• Attach specialist consultation notes or referral documentation to the imaging request.
• Document the specific surgical planning or level-based rationale provided by the specialist.

Research/data‑collection imaging may be denied

Do not request imaging studies solely for research or data collection that are not used in direct clinical management; such requests are not medically necessary and may be denied.

Overutilization (double contrast CT, MRI-for-radiation-avoidance) may trigger denial

Avoid ordering double contrast CT (CT without and with contrast) or replacing CT with MRI solely to avoid radiation without clinical justification; these overutilization scenarios may trigger additional review or denial.

• Double contrast CT requests have few indications and should be justified.
• CT should not replace MRI merely to avoid sedation unless recommended in a specific guideline section.

PA risk for 3D rendering codes

Providers may be required to obtain prior authorization for 3D rendering codes (CPT 76376/76377) even when the primary imaging does not require authorization; verify and document coverage requirements.

Whole‑body CT screening is not covered

Whole‑body CT or LifeScan screening for asymptomatic individuals is not a covered benefit and will be denied.

CPT 76380 not allowed for treatment planning

Use of CPT 76380 for treatment planning is considered not medically necessary and may be denied; do not bill 76380 for treatment‑planning purposes.

Requests without active signs/exam or prior x‑rays risk denial

Advanced imaging requests lacking documented active clinical signs/symptoms or without prior pertinent clinical evaluation (history, neurologic exam, plain radiography) risk denial.

• Ensure documentation shows active clinical findings or that imaging is guideline‑supported surveillance.
• Provide prior plain x-rays when the guideline requires them.

PA may be denied without prior plain radiographs

For many pediatric presentations, advanced imaging may be denied if plain radiography or appropriate clinical evaluation is not performed prior to consideration; ensure required plain x‑rays are completed and available.

• Plain x‑rays must be performed after the current episode of symptoms started/changed and results submitted with the request.
• Document why advanced imaging is necessary beyond plain radiography.

PA requirement: x‑rays and 4‑week conservative trial for age ≥6 without red flags

Advanced imaging in children age 6 and older requires prior plain x‑rays and documentation of results; absent red flags, include documentation of a 4‑week provider‑supervised conservative treatment trial before approval.

• Attach x‑ray reports performed after symptom onset/change.
• Document conservative treatment measures and duration when applicable.