CurrentevicorePolicy CMM-401

Discography

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Coverage policy for discography procedures (diagnostic injection of contrast into intervertebral discs) as applied to health benefit plans administered by Cigna and used by eviCore for medical necessity determinations.

Policy Summary

Payerevicore (for Cigna-administered plans)

PolicyDiscography

Policy CodePolicy CMM-401

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

Key ActionDocument trials of at least 6 weeks each of NSAIDs/muscle relaxants and conservative self-care or prescribed physical therapy before requesting discography.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50% / 2ptClinically meaningful improvement threshold

Auto-approvedPost-discography CT

Contrast onlyContrast requirement

6 wksConservative therapy duration

12+ wks

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CurrentevicorePolicy CMM-401

Discography

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Policy Summary

Payerevicore (for Cigna-administered plans)

PolicyDiscography

Policy CodePolicy CMM-401

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

Key ActionDocument trials of at least 6 weeks each of NSAIDs/muscle relaxants and conservative self-care or prescribed physical therapy before requesting discography.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50% / 2ptClinically meaningful improvement threshold

Auto-approvedPost-discography CT

Contrast onlyContrast requirement

6 wksConservative therapy duration

12+ wks

Required pain duration

Cervical/thoracicNot medically necessary examples

Coverage Criteria for Discography

Medical necessity criteria — Lumbar discography

Lumbar discography as a provocative diagnostic test for axial pain is considered medically necessary when ALL of the following criteria have been met:

Absence of red flags: Absence of red flag conditions

See Definitions for examples of red flag conditions

Failed conservative therapy: Less than clinically meaningful improvement despite BOTH: (1) nonsteroidal anti-inflammatory drugs (NSAIDs) and/or muscle relaxants for at least six (6) weeks; AND (2) conservative self-care (muscle stretching, regular exercise) or a prescribed physical therapy/core strengthening program for at least six (6) weeks

Both trials required

Pain pattern and exam suggesting disc disease: All of the following: subacute axial pain >12 weeks; axial pain worsening with upright posture; absence of signs and symptoms of radiculopathy; absence of trigger points in the affected area; absence of signs and symptoms of sacroiliac joint dysfunction

All listed exam features required

Absence of centralized pain syndromes (e.g., fibromyalgia, multicentric pain syndromes)

Imaging excludes other causes and suggests disc damage: Advanced imaging rules out other causes of pain such as facet joint disease AND imaging is suggestive of disc damage as evidenced by ANY of: annular tears; contained disc herniation; high-intensity zones

Imaging must both rule out other causes and show at least one listed disc abnormality

Qualified performers: Performed by EITHER the interventional pain physician or a supervising radiologist

Procedure must be performed by one of the listed qualified providers

Other injectates are not appropriate for lumbar discography. Lumbar discography must be performed with a contrast agent (with or without saline). Substances listed under Non‑Indications — for example, steroids or biologic injectates such as platelet‑rich plasma, stem cells, or amniotic fluid — are not considered appropriate injectates for this procedure.

Use of injectates other than contrast (with or without saline) for lumbar discography is explicitly disallowed. Lumbar discography performed with injectates other than contrast (with or without saline) is considered not medically necessary, and such procedures may be denied.

Results of discography alone will not determine medical necessity for subsequent procedures. Discography results will not be used as a determining factor of medical necessity for any requested procedure; the decision to authorize other interventions is made on a case‑by‑case basis using the full clinical record and applicable benefit terms.

Coding and Key Thresholds

Codes listed in guidelineCPT

62290	Injection procedure for discography, each level; lumbar
72295	Discography, lumbar, radiological supervision and interpretation

inv-07: Clinically Meaningful Improvement (VAS) threshold

Definition of clinically meaningful improvementAt least 50% pain relief OR a 2-point drop on a 0–10 VAS

VAS scale reference0 = no pain, 10 = worst pain imaginable

Use in criteria‘Less than clinically meaningful improvement’ required despite conservative therapy to qualify for discography

inv-08: Duration of conservative therapy required prior to testing

NSAIDs and/or muscle relaxants trialAt least 6 weeks

Conservative self-care/physical therapy trialAt least 6 weeks of conservative self-care (stretching, regular exercise) or prescribed physical therapy/core strengthening

Provider Actions, Documentation, and Authorization Notes

Prior Authorization

Case-by-case medical necessity; post-discography CT auto-approved

Determination of medical necessity for discography is made on a case-by-case basis; a post-discography CT scan is automatically approved as an add-on.

Billing Rule

Code listing — inclusion does not imply prior authorization

Codes listed for discography (e.g., 62290, 72295) are included for reference; inclusion does not imply the code requires prior authorization—refer to the applicable health plan for management details.

62290 — Injection procedure for discography, each level; lumbar
72295 — Discography, lumbar, radiological supervision and interpretation

Background

Discography is a targeted diagnostic procedure in which a contrast material (dye), with or without saline, is injected into the nucleus pulposus of an intervertebral disc to provoke pain and assess disc morphology. The policy requires the use of contrast for lumbar discography and makes clear that the procedure’s findings alone do not determine subsequent treatment authorization. A post‑discography CT scan is automatically approved as an add‑on when performed.

Definitions and Key Terms

inv-19: Definition of Discography

Basic definitionA diagnostic procedure in which contrast material (dye), with or without saline, is injected into the nucleus pulposus of a disc to determine whether the disc is the source of pain

Two presumed resultsPain provocation (reproduction of the individual's typical pain) and morphology assessment (e.g., annular tears, disc herniation) often based on CT

Clinical intentUsed to assist diagnosis of discogenic pain in individuals with predominantly axial back or neck pain

inv-20: Definition of Clinically Meaningful Improvement (>=50% or >=2-point VAS)

Threshold for meaningful improvement>= 50% pain relief OR >= 2-point drop on 0–10 VAS

Scale bounds0 = no pain; 10 = worst pain imaginable

Revision History

2026-08-04policy_effectiveLatest

Policy CMM-401 (Discography) published/updated and became effective, listing CPT codes 62290 and 72295 and stating code inclusion does not imply prior authorization or guarantee payment.

Policy Summary

Payerevicore (for Cigna-administered plans)

PolicyDiscography

Policy CodePolicy CMM-401

Change TypeNo material change

Effective DateAug 4, 2026

Next Review Date

Key ActionDocument trials of at least 6 weeks each of NSAIDs/muscle relaxants and conservative self-care or prescribed physical therapy before requesting discography.

SourceLink

On This Page

Both trials requiredBoth the medication trial AND the conservative therapy/PT trial must be completed without clinically meaningful improvement

inv-09: Required duration of pain prior to testing (subacute axial pain)

Minimum duration of pain> 12 weeks (subacute axial pain)

Associated exam featuresAxial pain worsening with upright posture; absence of radiculopathy, trigger points, and sacroiliac joint dysfunction

Role in indicationsSubacute axial pain >12 weeks is required as part of the pain pattern and exam suggesting disc disease

Note

Follow benefit plan terms for medical necessity determinations

The determination of medical necessity for the performance of a discography is always made on a case‑by‑case basis; follow applicable benefit plan terms, laws, and regulations when submitting requests.

Step Therapy

Conservative therapy prerequisites — documented trials required

Documented trials of conservative therapy are required prior to lumbar discography: at least six (6) weeks of NSAIDs and/or muscle relaxants AND at least six (6) weeks of conservative self‑care or prescribed physical therapy/core strengthening.

NSAIDs and/or muscle relaxants for ≥ 6 weeks
Conservative self‑care (muscle stretching, regular exercise) or prescribed physical therapy/core strengthening for ≥ 6 weeks

Prior Authorization

Case‑by‑case medical necessity; follow benefit plan requirements

Determinations of medical necessity are individualized; providers must follow the applicable benefit plan and relevant laws/regulations when submitting for review.

Documentation Required

Required clinical documentation for medical necessity

Required clinical documentation must include trials of at least six (6) weeks each of NSAIDs and/or muscle relaxants and conservative self‑care or prescribed physical therapy/core strengthening, absence of red flag conditions, exam findings consistent with disc disease, and advanced imaging findings suggestive of disc damage.

Documentation of ≥ 6 weeks NSAIDs and/or muscle relaxants
Documentation of ≥ 6 weeks conservative self‑care or prescribed PT/core strengthening
Absence of red flag conditions
Physical exam consistent with disc disease (e.g., subacute axial pain >12 weeks, pain worse with upright posture, absence of radiculopathy, absence of trigger points, absence of sacroiliac joint dysfunction)
Advanced imaging findings suggestive of disc damage (annular tear, contained herniation, high‑intensity zones)

Denial Risk

Discography results not determinative for subsequent procedures

Discography results must not be used as the determining factor of medical necessity for any subsequent requested procedure.

Denial Risk

Triggers for denial — not medically necessary scenarios

Requests may be denied when lumbar discography is performed without meeting the Definitions, General Guidelines, and Indications; when performed in the presence of any red flag condition; when non‑contrast injectates are used; or when cervical or thoracic discography is requested.

Performed without meeting Definitions, General Guidelines, and Indications
Performed in presence of any red flag condition
Performed with injectates other than contrast (with or without saline)
Cervical or thoracic discography

ApplicationUsed to determine 'less than clinically meaningful improvement' after conservative therapy in eligibility criteria

inv-21: Red flag conditions — presence contraindicates lumbar discography

Contraindicating conditionsPresence of ANY red flag condition contraindicates performance of lumbar discography and makes the procedure not medically necessary

Reference in policyAbsence of red flag conditions is required among indications for lumbar discography

ConsequencesProcedures performed in presence of red flag conditions may be denied as not medically necessary