Clinical Review Criteria — Lumbar Spine MRI (coverage criteria)
Defines medical necessity criteria, exclusions, and documentation/authorization requirements for lumbar spine MRI for Kaiser Foundation Health Plan of Washington members and their providers.
Functional MRI not covered except for Presurgical Planning Policy.
Required physical therapy quantified as 4 weeks (instead of prior 6 weeks) in criteria updates.
Added Functional MRI not covered except for Presurgical Planning Policy.
Modified MRI criteria to require 4 weeks of physical therapy (instead of 6 weeks).
Specified quantification of 3 visits for physical therapy for subacute low back pain.
Clarified evaluation language for confirmed or suspected neoplasm and role of MRI after low‑velocity trauma.
Oncologic staging or restaging of the spine MRI updates proposed.
Advanced imaging prior to a procedure is considered reasonable.
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