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CurrentevicorePolicy N/A

Spine Imaging Guidelines — Advanced Diagnostic Imaging Coverage (MRI/CT/MRA/Ultrasound)

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Rules and clinical criteria governing when advanced spine imaging (MRI, CT, MRA, MR spectroscopy, ultrasound) is medically necessary for Cigna plans managed by eviCore; applies to cervical, thoracic, lumbar spine and pelvis regions.

Policy Summary

Payerevicore

PolicySpine Imaging Guidelines — Advanced Diagnostic Imaging Coverage (MRI/CT/MRA/Ultrasound)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2026

Next Review DateN/A

Key ActionPrior authorization is required for the listed advanced spine imaging CPT codes and providers must document an in-person clinical evaluation plus required conservative treatment/trials or applicable red-flag findings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6-weekRequired conservative trial

Red flagRed flag exceptions

MultipleProcedure codes listed

Cervical/Thoracic/Lumbar/PelvisAnatomic regions covered

MR Spectroscopy/Positional MRI/PET CTNot medically necessary examples

Coverage Criteria — When Advanced Spine Imaging Is Medically Necessary

inv-01: General coverage and red flag exception

Advanced diagnostic imaging is covered when documentation meets general clinical requirements; listed Red Flag Indications permit imaging without the usual conservative trial.

Standard requirements: All of the following must be met: 1) an in-person clinical evaluation with relevant history and a detailed neurological exam (motor, sensory dermatomes, reflexes, nerve tension signs); 2) documentation of clinical re-evaluation after a trial of provider-directed conservative therapy (typically six weeks) showing failure of clinical improvement; 3) when specified, plain x-rays performed after the current episode of symptoms started or changed with results available to the requesting provider; 4) documentation of specific exam findings (motor grading, dermatomal sensory changes, reflex asymmetry) appropriate to the indication.6-week trial

Clinical re-evaluation may be in-person or other meaningful contact; initial evaluation must be in-person.

Red flag indications (exception to 6-week trial): Advanced diagnostic imaging is medically necessary without completion of a six-week conservative trial when any of the following red flag indications are present: Motor Weakness; Aortic Aneurysm or Dissection; Cancer; Cauda Equina Syndrome; Fracture; Infection; Severe Radicular Pain.

Policy Summary

Payerevicore

PolicySpine Imaging Guidelines — Advanced Diagnostic Imaging Coverage (MRI/CT/MRA/Ultrasound)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2026

Next Review DateN/A

SourceLink

On This Page

Red Flag Indications reflect potential life- or limb‑threatening conditions and obviate the standard conservative care requirement.

inv-02: Red Flag Indications — general rule

Advanced diagnostic imaging is medically necessary for Red Flag Indications — life- or limb-threatening conditions where imaging is an exception to the standard conservative trial.

Red Flag categories: Motor Weakness; Aortic Aneurysm or Dissection; Cancer; Cauda Equina Syndrome; Fracture; Infection; Severe Radicular Pain

Presence of any listed red flag permits advanced imaging without a six-week conservative treatment trial.

inv-03: Motor Weakness — ANY of the following are present on in-person evaluation

Covered when ANY of the following are present on in-person evaluation:

Motor weakness criteria: New onset motor weakness of grade 3/5 or less in specified muscles; new onset foot drop; new onset bilateral lower extremity weakness; or progressive objective motor, sensory, or deep tendon reflex deficits on clinical re-evaluation.

Imaging: MRI of the relevant spinal level without contrast or MRI without and with contrast. SI joint/sacrum are captured with pelvic imaging.

inv-04: Aortic Aneurysm or Dissection — Covered when presenting with

Covered when presenting with:

AAA/dissection: New onset back and/or abdominal pain in an individual with a known aortic aneurysm, or when acute aortic dissection is suspected.

Policy directs that spine imaging is not the appropriate study for these presentations; refer to Peripheral Vascular Disease Imaging Guidelines (PVD-6) for vascular imaging.

inv-05: Cancer — suspected spinal malignancy criteria

Covered when there is clinical suspicion of spinal malignancy AND one or more listed features:

Cancer suspicion: Clinical suspicion of spinal malignancy AND at least one of: night pain; uncontrolled or unintended weight loss; pain unrelieved by change in position; age >70 years; severe or worsening spinal pain.

Imaging options include MRI of the relevant spinal level without contrast or without and with contrast, CT without contrast, or CT myelography; SI joint/sacrum included with pelvic imaging. For known history of cancer see Oncology Imaging Guidelines (ONC-31.6).

inv-06: Cauda Equina Syndrome — ANY of the following acute findings

Covered when ANY of the following acute findings present on in-person evaluation:

Cauda equina signs: Acute bilateral sciatica; perineal sensory loss (saddle anesthesia); decreased anal sphincter tone; new bowel or bladder incontinence; or otherwise unexplained acute urinary retention.

Imaging: MRI lumbar spine without contrast (CPT 72148) OR MRI lumbar spine without and with contrast (CPT 72158).

inv-07: Fracture — fracture-related coverage scenarios

Covered under the following fracture-related scenarios:

Fracture scenarios: Clinical suspicion of a pathological spinal fracture (advanced imaging after x-ray); suspicion of a spinal fracture after trauma (advanced imaging after x-ray); or suspicion of fracture related to ankylosing spondylitis or DISH (advanced imaging without plain x‑ray).

See specific trauma and compression fracture sections (SP-3.2, SP-4.2, SP-6.2, SP-11.1, SP-10.2) for modality selection and workflow.

inv-08: Infection — criteria and risk factors for imaging

Covered when there is clinical suspicion of spinal infection AND one or more listed risk factors or signs:

Infection suspicion: Clinical suspicion of spinal infection (disc space infection, epidural abscess, spinal osteomyelitis) AND at least one of: fever; IV drug use; recent systemic bacterial infection; recent spinal intervention; immunocompromised state; long‑term systemic steroids; organ transplant on anti‑rejection meds; diabetes; HIV/AIDS; chronic dialysis; immunosuppressant therapy; neoplastic spine involvement; laboratory values indicative of infection (elevated WBC/ESR/CRP or positive cultures); decubitus ulcer over spine; abnormal x‑ray/CT suspicious for infection; new neurologic deficit; or cauda equina syndrome.

Advanced imaging options include: MRI of the relevant level without and with contrast or without contrast; CT with or without IV contrast; whole-body FDG‑PET/CT when x‑ray/CT abnormal and MRI cannot be performed or is inconclusive; 3‑phase bone scan; bone SPECT or SPECT/CT; Gallium scans with optional SPECT/SPECT‑CT. SI/sacrum captured with pelvic imaging.

inv-09: Severe Radicular Pain — ALL of the following (in-person eval required)

Covered when ALL of the following are present (in-person evaluation required):

Severe radicular pain criteria: Severe radicular pain in a specified spinal nerve root distribution (Visual Analog Scale ≥9/10) AND documented significant functional loss at work or home AND pain unresponsive to at least seven (7) days of provider‑directed treatment AND the treatment plan includes one of: transforaminal epidural steroid injection at any level; interlaminar epidural steroid injection at cervical or thoracic levels; plan for urgent/emergent spinal surgery; or plan for urgent/emergent referral/consultation by a spine specialist.>=9/10; >=7 days

Imaging: MRI of the relevant spinal level without contrast OR MRI without and with contrast. SI/sacrum captured with pelvic imaging.

inv-10: MRI Indications — general MRI spine medically necessary indications

MRI Spine is considered medically necessary for the following general indications:

MRI indications: Evaluation of disc disease, spinal cord and nerve root disorders; suspicion or surveillance of known spine/spinal cord neoplastic disease; suspicion, diagnosis or surveillance of spinal infections, multiple sclerosis, myelitis, syringomyelia, cauda equina syndrome, or other red flag indications; pre‑operative evaluation to define abnormal or variant spinal anatomy that could influence surgery; post‑operative evaluation when history/exam is suspicious for hematoma, infection, or CSF leak.

Contrast use per contrast rules; MR Spectroscopy for spine uses is not medically necessary.

inv-11: CT Indications — CT spine medically necessary circumstances

CT Spine is considered medically necessary in the following circumstances:

CT indications: When MRI is contraindicated (documented implanted ferromagnetic material or non‑MRI‑compatible device); for spinal trauma/fractures especially risking instability or cord/nerve compression; for spinal neoplastic disease; in conjunction with myelography or discography; for pre‑operative evaluation of bony anatomy; assessment of suspected pseudoarthrosis after fusion; congenital/developmental/acquired spinal deformity; spondylolysis when x‑rays are negative or MRI equivocal; evaluation of calcified lesions (e.g., osteophytes, OPLL). CT may be performed even if MRI has already been obtained for these indications.

CT may be performed with or without IV contrast as indicated.

inv-12: CT/Myelography Indications

CT/Myelography:

CT/Myelography indications: Generally unnecessary as an initial study when a diagnostic quality MRI has been obtained; indicated to clarify equivocal, indeterminate, or non‑diagnostic MRI findings; when MRI is contraindicated; for pre‑operative planning when MRI is insufficient; and for post‑operative evaluation when MRI is contraindicated or non‑diagnostic.

Guidelines allow approval only for post‑myelogram CT procedure codes (CPT 72126, 72129, 72132); other myelogram procedure codes (e.g., CPT 72265, 62284) are not approved.

inv-13: Post-discography CT

Post-lumbar discography CT:

Post-discography CT: A post‑discography CT is medically necessary only following an approved lumbar discography and must be coded and performed as CT lumbar spine without contrast (CPT 72131).

Authorization for post‑discography CT will be issued only when the discography has already been approved.

inv-14: Spinal Canal Ultrasound Indications (CPT 76800)

Spinal canal ultrasound (CPT 76800):

Ultrasound indications: Generally limited to newborns/infants/young children because of incomplete vertebral ossification; evaluation of suspected tethered cord; assessment of occult or non‑occult spinal dysraphism; evaluation of spinal cord tumors or vascular malformations in children; intraoperative use (reported with CPT 76998 rather than CPT 76800).

Contraindicated for adult assessment of spinal pain, radiculopathy, facet or nerve root inflammation, disc herniation, or deep soft tissue conditions.

inv-15: Vertebral Hemangiomas and Tarlov Cysts guidance

Miscellaneous spinal lesions guidance:

Vertebral hemangioma guidance: Typical vertebral body hemangiomas on plain x‑ray usually do not require further advanced imaging unless there are associated neurologic signs or symptoms; if atypical on plain x‑ray, MRI without contrast or MRI without and with contrast is medically necessary; if MRI is equivocal, CT without contrast is medically necessary. No routine follow‑up imaging is required once diagnosis is established without neurologic features.

Tarlov cyst guidance: Tarlov cysts are commonly incidental; further evaluation of a known or suspected Tarlov cyst can be performed with MRI lumbar spine without and with contrast (CPT 72158) or CT/myelography lumbar spine (CPT 72132) when clinically indicated.

inv-16: Vertebral body hemangiomas — when covered

Covered when criteria direct further imaging

Vertebral body hemangioma imaging: If typical on plain x‑ray, no further advanced imaging is usually required unless neurologic symptoms/signs are present; if atypical on plain x‑ray (with or without neurologic signs), MRI without contrast or MRI without and with contrast is medically necessary; if MRI is equivocal/indeterminate, CT without contrast is medically necessary; no follow‑up imaging needed once diagnosis established without neurologic features.

Documentation supporting atypical appearance should be provided when requesting MRI.

inv-17: Tarlov cysts — imaging options for known/suspected

Covered imaging options for known or suspected Tarlov cysts

Tarlov cyst imaging: Further evaluation can be performed with MRI lumbar spine without and with contrast (CPT 72158) or CT/myelography lumbar spine (CPT 72132) when clinically indicated for a known or suspected Tarlov cyst.

Usually benign and incidental; controversy exists regarding symptom causation.

inv-18: Other spinal lesions — covered when ALL of the following are met

Covered when ALL of the following are met

Other spinal lesions imaging: (1) Other spinal lesions are seen on routine x‑rays or a non‑contrast MRI; AND (2) additional advanced imaging (MRI with/without contrast or CT without contrast) is recommended by a spine specialist or radiologist to further characterize or diagnose the lesion; OR (3) advanced imaging is required for surgical planning.

MRI with/without contrast or CT without contrast is medically necessary in these situations.

inv-19: Spinal MRA — selected indications

MRA Spine may be considered for selected indications

MRA Spine indications: Indications include suspected spinal cord AVM/AVF (start with MRI without and with contrast; if high suspicion proceed to catheter angiography), subarachnoid hemorrhage without identified brain aneurysm (catheter angiography recommended), and pre‑operative planning to identify feeder vessels; catheter angiography is generally more definitive. CSF flow studies are included in certain brain MRI CPT codes and should not be billed separately.

3D rendering codes may be medically necessary with spinal angiography.

inv-20: PET/CT and Cone-beam CT — coverage and exclusions

Spine PET/CT is considered not medically necessary for routine assessment of spinal disorders due to inadequate scientific evidence except when assessing neoplastic disease (see oncology imaging guidance).

Cone‑beam CT cervical spine: Cone‑beam CT for imaging of the cervical spine is considered not medically necessary; use outside the operative setting is not supported by evidence.

inv-21: Neck (Cervical) Pain without/with Neurological Features (SP-3.1)

Advanced diagnostic imaging is covered when ALL of the following are met:

Cervical pain imaging preconditions: 1) An in‑person clinical evaluation for the current episode has been performed; 2) Failure of a 6‑week trial of provider‑directed treatment after the current symptoms/exam started or changed (unless a red flag is present); 3) Clinical re‑evaluation after the treatment period (in‑person or other meaningful contact).

inv-22: Cervical advanced imaging modality selection

When criteria are met:

Modality selection: MRI cervical spine without contrast (CPT 72141) is the preferred advanced modality. CT cervical spine without contrast (CPT 72125) or CT myelography (CPT 72126) is medically necessary when MRI is contraindicated.

inv-23: Neck (Cervical) Trauma (SP-3.2)

Advanced imaging is covered when ALL of the following are met (except where noted):

Cervical trauma preconditions: 1) An in‑person clinical evaluation for the current episode has been performed; 2) Failure of a 6‑week trial of provider‑directed treatment after the current symptoms/exam started or changed (unless red flag); 3) Clinical re‑evaluation after the treatment period; 4) Results of plain x‑rays of the cervical spine performed after the current episode started or changed need to be available to the requesting provider (not required for high‑risk mechanisms).

inv-24: Cervical trauma modality selection and exceptions

When criteria are met or exceptions apply:

Modality selection in trauma: MRI cervical spine without contrast (CPT 72141) OR CT cervical spine without contrast (CPT 72125). For individuals with ankylosing spondylitis or DISH, MRI of the entire spine (CPT 72141, 72146, and/or 72148) AND CT of the entire spine (CPT 72125, 72128, and/or 72131) are medically necessary. Plain x‑rays and the 6‑week trial/re‑evaluation are NOT required for individuals with high‑risk factors for cervical spine injury within the last 3 months.

inv-25: Thoracic spine pain (SP-4.1) and trauma (SP-4.2) coverage

Advanced imaging is covered when ALL of the following are met for thoracic indications:

Thoracic pain preconditions: 1) An in‑person clinical evaluation for the current episode; 2) Failure of a 6‑week trial of provider‑directed treatment (unless red flag); 3) Clinical re‑evaluation after treatment period; 4) Plain x‑rays are required for thoracic back pain without neurological features (unless red flag).

Thoracic trauma preconditions: Same as above, except conservative treatment and clinical re‑evaluation are not required in high‑risk individuals (acute traumatic injury with midline thoracolumbar tenderness, high‑energy mechanisms, or age >60).

Thoracic modality selection: MRI thoracic spine without contrast (CPT 72146) is preferred. CT thoracic spine without contrast (CPT 72128) or CT myelography (CPT 72129) is medically necessary when MRI is contraindicated. For individuals with AS or DISH, whole‑spine MRI and CT are medically necessary and the 6‑week trial/re‑evaluation are not required.

inv-26: Low Back (Lumbar Spine) Pain without Neurological Features — Advanced Imaging

Advanced MRI/CT of the lumbar spine is covered when ALL of the following are met:

Clinical evaluation: An in‑person clinical evaluation for the current episode (initial or re‑evaluation) has been performed before advanced imaging is considered.