Kaiser Permanente Thoracic Spine MRI Coverage Update

Clinical Coverage Criteria — Thoracic Spine MRI

I. Acute thoracic back pain — red flag indications

Covered when ONE or more of the following red flag conditions are present for acute thoracic back pain:

Red flags for acute thoracic back pain: 1. Objective neurological signs of thoracic myelopathy (leg weakness and incontinence with +/- spasticity) — MRI without contrast. 2. Progressive (objective) neurological signs of thoracic myelopathy during conservative care (progressive motor weakness) — MRI without contrast. 3. Strong clinical suspicion of spine infection with concern for thoracic myelopathy or myelitis — MRI with and without contrast and TWO or more of: fever; immunosuppression (e.g., chronic steroid use, diabetes); IV drug use; known bacteremia; elevated ESR/CRP. 4. Evaluation for neoplastic process in a patient with new back pain and confirmed cancer likely to involve the skeleton AND non-diagnostic plain films/CT or evidence of bony pathology on plain films/CT — MRI with and without contrast. 5. Suspected cancer with non-diagnostic plain films/CT plus TWO of: unexplained weight loss; age >50; failure of back pain to improve after one month — MRI with and without contrast.

II. Subacute thoracic back pain

Covered when ALL of the following are met for subacute thoracic back pain (>6 weeks):

Subacute criteria: 1. At least 6 weeks of medical/conservative treatment for the current episode (must include at least 4 weeks of physical therapy including an initial PT evaluation and at least one follow-up within the last 3 months) with no significant improvement (remote PT does not qualify); if diabetic, diabetes should be well controlled.

Additional required findings: AND one of the following: any acute red flag criterion (section I); suspected thoracic radiculopathy (band of numbness, pain or sensitivity around the midsection); OR motor weakness or sensory loss in a spinal cord distribution (e.g., bilateral sensory loss from mid/low abdomen downward, leg weakness, bowel or bladder incontinence).

III. Chronic thoracic back pain without prior MRI

Covered when ALL of the following are met for chronic thoracic back pain (>3 months) with no prior thoracic MRI:

Chronic without prior MRI: 1. At least 6 weeks of medical/conservative treatment for the current episode (must include at least 4 weeks of physical therapy with an initial PT evaluation and at least one follow-up within the last 6 months) with no significant improvement (remote PT does not qualify). 2. Meets ONE of the criteria under subacute thoracic back pain (section II).

IV. Chronic thoracic back pain with prior MRI

Covered when ALL of the following are met for chronic thoracic back pain (>3 months) with prior thoracic MRI:

Chronic with prior MRI: 1. At least 6 weeks of medical/conservative treatment for the current episode (must include at least 4 weeks of physical therapy with an initial PT evaluation and at least one follow-up within the last 6 months) with no significant improvement (remote PT does not qualify). 2. Meets ONE of the criteria under subacute thoracic back pain (section II). If the clinical exam is unchanged from prior, MRI should not be repeated more than once every 12 months.

V. Vertebral compression fracture

Covered for evaluation of vertebral compression fracture (MRI without contrast) when ONE of the following applies:

Suspected or confirmed vertebral compression fracture: Suspected vertebral fracture with pain and non-diagnostic plain films/CT plus osteoporosis OR age >70 with other acute fractures; OR confirmed vertebral compression fracture on plain films/CT with signs or symptoms of acute cord/cauda equina compression due to retropulsion (e.g., acute numbness, weakness, paresthesia, and/or bladder/bowel dysfunction), OR signs/symptoms of acute nerve root impingement due to retropulsion (e.g., acute radiculopathy), OR suspected pathologic fracture (mechanism such as low velocity trauma does not explain fracture), OR preoperative planning for vertebral augmentation (vertebroplasty, kyphoplasty, other implantable VA methods).

V–VI. Demyelinating and inflammatory indications

Covered when ordered by or after consultation with neurology for suspected demyelinating disease or MS with specific indications:

MS and demyelinating indications: V. Suspected thoracic MS: patient evaluated by neurology who specifically advises thoracic MRI; not part of initial staging unless there are specific thoracic findings (e.g., MS 'hug' or sensory loss beginning mid thorax). VI. Inflammatory/demyelinating processes (e.g., transverse myelitis, clinically isolated syndrome, Brown-Sequard, autoimmune inflammatory disorders, MS suspected but brain/cervical MRI nondiagnostic): order after neurology/neurosurgery consultation; MRI with contrast where indicated.

VIII. Scoliosis indications

Covered for pediatric/adolescent and adult scoliosis when ONE or more listed features are present:

Pediatric/Adolescent scoliosis: Indications include congenital scoliosis; early-onset scoliosis (age ≤9 years); neurofibromatosis; presurgical planning for adolescent idiopathic scoliosis with abnormal neurologic findings; age at first visit ≤10 years; kyphosis at curve apex; left-sided thoracic curvature; male gender; moderate to severe pain; rapid curve progression (>1 degree/month); short segment curve (<6 vertebrae); thoracic kyphosis ≥30°; vertebral abnormalities on x-ray (e.g., hemivertebra, block vertebra).

Adult scoliosis: Indications include abnormal neurologic findings, kyphosis at curve apex, moderate to severe pain, rapid curve progression (>1 degree/month), short segment curve (<6 vertebrae), thoracic kyphosis ≥30°, vertebral abnormalities on x-ray, and presurgical planning.

VIII–VII. Spinal stenosis

Covered for suspected thoracic spinal stenosis when patient is being considered for invasive treatment and has progressive or disabling symptoms:

Thoracic spinal stenosis: 1. Patient being considered for invasive treatment. 2. Progressive or disabling symptoms as indicated by one or more of: hyperactive reflexes; muscle weakness; sensory loss; spasticity.

IX–X. Oncologic and radiotherapy planning

Covered for stereotactic spine radiotherapy treatment planning and oncologic staging/restaging:

Oncologic indications: Stereotactic spine radiotherapy treatment planning; oncologic staging or restaging for known or suspected neoplastic process involving the spine or associated structures based on pathology or another imaging study.

XI–XII. Syringomyelia and tethered cord

Covered when clinical features suggest syringomyelia or tethered cord:

Syringomyelia indications: One or more of muscle wasting, sensory loss, weakness in appropriate thoracic dermatomes, or bowel/bladder dysfunction.

Tethered cord indications: One or more of: anorectal malformation; cutaneous manifestations of occult spina bifida (e.g., nevus, lipoma, tuft of hair, hemangioma, dimple, asymmetric gluteal cleft, dermal sinus tract); gait abnormality; urinary dribbling or lack of bladder control; abnormal urodynamic tests.

XIII. Ankylosing Spondylitis

Advanced imaging for suspected or confirmed AS when ALL specified criteria met:

Suspected AS: A. Suspected AS: radiographs of the affected area are not diagnostic; inflammatory back pain present ≥3 months with at least 4 of: age <40; insidious onset; improvement with exercise; no improvement with rest; night pain improving on getting up; AND advanced imaging ordered by or in conjunction with a Rheumatologist.

Confirmed AS: B. Confirmed AS: advanced imaging ordered by the patient's managing Rheumatologist; unclear disease activity after full clinical and laboratory evaluation; and MRI progression would lead to a change in biologic therapy or cessation of biologic therapy.

XIV. Indication not listed

Indication not listed:

Unlisted indication: Provide clinical justification; indications should be well documented.

Functional MRI of the thoracic spine is not covered except when used for presurgical planning as defined under the organization's Presurgical Planning Policy. Requests for functional MRI outside of presurgical planning will be denied as an excluded service.

Thoracic spine MRI is not considered medically necessary for acute thoracic back pain when no red flag conditions are documented. For subacute or chronic thoracic back pain, MRI is not indicated when required conservative management (minimum of 6 weeks of medical/conservative treatment including at least 4 weeks of physical therapy with initial evaluation and at least one follow-up within the specified window) and the qualifying clinical findings are not present.

inv-22: Appropriate clinical indications for thoracic spine MRI per sections I–XIII

Appropriate clinical indications for thoracic spine MRI per sections I–XIII:

Appropriate clinical indications for thoracic spine MRI per sections I–XIII: Objective myelopathy or progressive neurological deficits; suspected spine infection with systemic findings; suspected or confirmed neoplasm with supporting imaging/history; vertebral compression fracture with specified features or preoperative planning for vertebral augmentation; indications for stereotactic spine radiotherapy planning or oncologic staging/restaging; syringomyelia; tethered cord; ankylosing spondylitis when criteria met; scoliosis with listed features; spinal stenosis when being considered for invasive treatment and progressive or disabling symptoms; and demyelinating/inflammatory indications when ordered by or after neurology consultation.

CPT/HCPCS Coding

Considered Medically Necessary when criteria metCPTCovered

72146	MRI Thoracic without contrast
72147	MRI Thoracic with contrast
72157	MRI Thoracic without and with contrast

Provider Actions, Prior Auth & Documentation

Prior Authorization

Prior authorization and code verification — High‑End Imaging Site of Care review required

High-End Imaging Site of Care review is required for requests performed in a hospital-based imaging department for non‑Medicare members. Verify code-specific prior authorization requirements using the Pre-authorization Code Check for CPT codes 72146, 72147, and 72157.

High-End Imaging Site of Care review applies to hospital-based imaging for non‑Medicare members.
Use Pre-authorization Code Check to confirm authorization per plan and CPT (72146, 72147, 72157).

Step Therapy

Conservative care requirement — minimum conservative therapy and PT follow-up

For subacute, chronic, or repeat thoracic MRI scenarios, patients must have received at least 6 weeks of medical/conservative treatment that includes a minimum of 4 weeks of physical therapy (initial PT evaluation plus at least one follow-up) within the specified recent time window and with no significant improvement.

Summary of Appropriate Indications

inv-22: Appropriate clinical indications for thoracic spine MRI per sections I–XIII — top-level summary node

Top-level summary of appropriate clinical indications (sections I–XIII):

Top-level summary: Indications include: objective thoracic myelopathy or progressive neurologic deficits; suspected spinal infection with systemic signs; vertebral compression fracture with high-risk features; suspected or confirmed spinal neoplasm with non-diagnostic radiographs/CT; indications for stereotactic spine radiotherapy or oncologic staging/restaging; syringomyelia or tethered cord features; ankylosing spondylitis meeting imaging criteria; scoliosis with listed pediatric or adult features; and thoracic spinal stenosis when invasive treatment is being considered with progressive/disabling symptoms.

Repeat Imaging Frequency

inv-23: MRI frequency limit — repeat MRI not more than once every 12 months if exam unchanged

Frequency limitRepeat thoracic spine MRI should not be performed more than once every 12 months if the clinical exam is unchanged from prior.

Applies toChronic thoracic back pain with prior thoracic MRI (no new red flags).

Conservative care prerequisiteAll patients must have had ≥6 weeks of medical/conservative treatment including ≥4 weeks of physical therapy (initial evaluation + ≥1 follow-up) for the current episode without significant improvement before repeat MRI is covered.

Contrast guidanceRepeat MRI without contrast is specified when no red flags are present; contrast used when indicated by infection, neoplasm, or demyelinating/inflammatory suspicion.

DocumentationClinical exam comparison to prior imaging/notes must demonstrate change to justify interval <12 months.

Use of Gadolinium Contrast

Billing Rule

CONTRAST RULES — MRI with and without contrast for infection, neoplasm, demyelinating/inflammatory indications

Use MRI with and without contrast for suspected spine infection, neoplasm evaluation when indicated, and certain demyelinating/inflammatory indications; many other indications specify MRI without contrast.

Infection with concern for myelopathy or myelitis: MRI with and without contrast plus TWO or more systemic findings (fever, immunosuppression, IV drug use, known bacteremia, elevated ESR/CRP).
Evaluation for neoplasm when indicated (e.g., confirmed cancer with non‑diagnostic plain films/CT or evidence of bony pathology): MRI with and without contrast.
Suspected thoracic MS or inflammatory/demyelinating processes: MRI with contrast when ordered per neurology/neurosurgery guidance.

Services Not Covered

NOT COVERED: Functional MRI of the thoracic spine is excluded from coverage except when performed for presurgical planning in accordance with the Presurgical Planning Policy. Such functional MRI requests outside that specific use will not be covered.

Definitions and Red Flags

inv-21: Red flags — objective neurologic signs, progressive deficits, suspicion for infection/neoplasm

Objective neurological signs of thoracic myelopathyLeg weakness and incontinence with or without spasticity — MRI without contrast.

Progressive neurological deficitsProgressive (objective) neurologic signs of thoracic myelopathy on repeat exam during conservative care (progressive motor weakness) — MRI without contrast.

Suspected spine infectionStrong clinical suspicion of spine infection with concern for thoracic myelopathy or myelitis — MRI with and without contrast and TWO or more systemic findings (fever; immunosuppression; IV drug use; known bacteremia; elevated ESR/CRP).

Evaluation for neoplasmNew back pain with confirmed cancer likely to involve skeleton plus non-diagnostic plain films/CT or evidence of bony pathology on plain films/CT — MRI with and without contrast.

Supporting systemic signs for infectionAt least two of: fever; immunosuppression (eg, chronic steroid use, diabetes); IV drug use; known bacteremia; elevated ESR/CRP.

Background and Scope

BACKGROUND: Thoracic spine MRI is used to evaluate acute, subacute, and chronic thoracic back pain and to assess specific neurologic, infectious, neoplastic, inflammatory, and structural conditions. MRI technique (with or without contrast) is selected based on the suspected pathology, for example MRI without contrast for many mechanical and degenerative indications and MRI with and without contrast when infection, neoplasm, or certain demyelinating/inflammatory processes are suspected. Prior authorization and site-of-care review requirements apply for hospital-based imaging for non‑Medicare members; verify code-specific authorization using the Pre-authorization Code Check.

Policy Revision History

2026-02-03revisedLatest

Added exclusion: Functional MRI of the thoracic spine not covered except when used for Presurgical Planning Policy.

2025-03-04revised

MPC approved updates for oncologic staging or restaging of the spine to the thoracic MRI criteria; effective August 1, 2025 after 60-day notice.

2024-10-03added

Clinical Review Criteria — Thoracic Spine MRI

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