CurrentUnitedHealthcarePolicy CSRADOI4OH.D

Adult Spine Imaging Guidelines (For Ohio Only)

UnitedHealthcare Community Plan clinical guideline for appropriate advanced imaging and related procedures of the adult spine applicable only to members in Ohio, covering modality selection (X-ray, CT, MRI, US, PET, nuclear medicine), clinical documentation requirements, and coding/billing guidance across multiple spine conditions.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Spine Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRADOI4OH.D

Change TypeAnnual and interim evidence-based updates (no material clinical change)

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionProviders must submit detailed recent history, physical exam, onset/change in symptoms, labs, prior imaging and X-rays from current episode for spine imaging requests to establish medical necessity.

POLICY UPDATE CHANGES

Summaries: Annual and interim evidence-based updates; no specific single clinical change highlighted in this part.

Ohio onlyGeographic scope

6 weeksConservative therapy trial prior to imaging

9/10Severe radicular pain VAS threshold

multipleCovered Modalities

V1.0.2025

Coverage Summary & Scope

This UnitedHealthcare Community Plan coverage guideline (Policy Number: CSRADOI4OH.D) is an evidence-based clinical policy for advanced imaging and related procedures of the adult spine applicable to members in Ohio only. The guideline version is V1.0.2025 and the effective date is November 1, 2025. It was developed from society guidance and peer-reviewed literature to guide appropriate modality selection, define documentation and coding expectations, and limit overutilization while allowing clinician judgment in specific circumstances.

Key facts

PayerUnitedHealthcare Community Plan

ScopeOhio adults (state-specific guideline applies to Ohio only)

Effective dateNovember 1, 2025

Policy numberCSRADOI4OH.D

Guideline versionV1.0.2025

Coverage stanceMixed (coverage guidance with specified covered modalities, restrictions, and not medically necessary determinations)

Medical-Necessity Criteria (Decision Trees)

Neck (Cervical Spine) Trauma - High Risk Factors (SP-3.2)

All criteria below must be met for advanced cervical spine imaging in trauma/high-risk scenarios.

ALL of the following

High-risk factors present after blunt neck (cervical spine) trauma (any of the following): age >65 years; dangerous mechanism of injury (e.g., fall from elevation >3 feet/5 stairs, high-speed motor vehicle collision, axial load to head, rollover, ejection); focal neurological deficit; paresthesias in extremities; intoxication with inability to reliably exam; distracting injury preventing reliable examination; or midline cervical tenderness.
SP-3.2: presence of ANY high-risk factor warrants advanced imaging (CT cervical spine preferred in acute trauma).
Imaging modality note
- CT cervical spine without contrast is the preferred initial advanced imaging in acute trauma for evaluation of bony injury.
  Use CT over radiographs when high-risk factors present.

Region- & Condition-Specific Imaging Criteria

MRI Spine (SP-2.2) - general

MRI Spine indications: Evaluation of disc disease, spinal cord and nerve root disorders and most other spinal conditions including congenital anomalies.

Contrast guidance: MRI of the spine may be performed without contrast; with contrast; or without and with contrast. A 'with contrast' study alone is indicated only to complete a study begun without contrast. Contrast is generally not indicated for most disc and nerve root disorders, fractures and degenerative disease.

Not medically necessary: MR Spectroscopy for all spine uses is considered not medically necessary. Positional (dynamic/weight-bearing/kinetic) MRI is considered not medically necessary due to inadequate evidence.

CT Spine (SP-2.3) - indications

CT Spine indications:

Not Medically Necessary / Experimental Modalities

Not Medically Necessary

Not Medically Necessary / Not Covered: The following spine imaging modalities, techniques, and related services are considered not medically necessary, not covered, or experimental/ investigational for spine imaging when requested for indications addressed by this guideline. Items listed under an ALL operator require that all listed conditions be met to consider exception; otherwise they remain not covered.

ALL of the following

MR spectroscopy of the spine (single-voxel or multivoxel) is not medically necessary for evaluation of spine pain, radiculopathy, myelopathy, infection, neoplasm, or routine post-operative assessment.
Positional or weight-bearing MRI of the spine (including upright MRI) is not medically necessary for routine evaluation of spine pain or radiculopathy when standard supine MRI is available and sufficient.
Cone-beam CT (CBCT) of the spine is not medically necessary for routine diagnostic evaluation of the spine when standard CT or MRI techniques are available and adequate.

Coding Guidance & Code Groups

MRI Cervical/Thoracic/Lumbar and related CPT codes (spine)CPTCovered

72141	MRI Cervical without contrast
72142	MRI Cervical with contrast
72156	MRI Cervical without and with contrast
72146	MRI Thoracic without contrast
72147	MRI Thoracic with contrast
72157	MRI Thoracic without and with contrast
72148	MRI Lumbar without contrast
72149	MRI Lumbar with contrast
72158	MRI Lumbar without and with contrast

Spine CT codesCPTCovered

72125	CT Cervical without contrast
72126	CT Cervical with contrast (Post-Myelography CT)
72128	CT Thoracic without contrast
72129	CT Thoracic with contrast (Post-Myelography CT)
72131	CT Lumbar without contrast (Post-Discography CT)
72132	CT Lumbar with contrast (Post-Myelography CT)
72133	CT Lumbar without and with contrast
72192	CT Pelvis without contrast
72193	CT Pelvis with contrast
72194	CT Pelvis without and with contrast

MRA / Pelvis / MR Spectroscopy and other MRI codesCPTCovered

72159	MRA Spinal Canal
72195	MRI Pelvis without contrast
72196	MRI Pelvis with contrast
72197	MRI Pelvis without and with contrast
76390	MR Spectroscopy (listed in procedure codes; note policy: MRS is considered not medically necessary for all spine uses)

SPECT/CT and nuclear medicine codesCPTCovered

78102	Bone Marrow Imaging; Limited
78104	Bone Marrow Imaging, Whole Body
78300	Bone or Joint Imaging; Limited
78305	Bone or Joint Imaging; Multiple
78306	Bone Scan, Whole Body
78315	Bone Scan, 3 Phase Study
78800	Radiopharmaceutical localization (includes vascular flow)
78801	Radiopharmaceutical localization, planar, 2+ areas
78802	Radiopharmaceutical localization, whole body single imaging day
78830	SPECT with concurrently acquired CT (SPECT/CT)

1–10 of 11

1/2

PET-MRI coding combinationmixed

78813	PET Whole-Body (use in combination with MRI Unlisted for PET-MRI)
76498	MRI unlisted code - used to report Whole-Body MRI or MRI Unlisted when reporting PET-MRI as specified

3D rendering codes (billing guidance)CPT

76376	3D rendering, not requiring image post-processing on an independent workstation
76377	3D rendering requiring image post-processing on an independent workstation

Imaging guidance / interventional guidance codesCPT

75989	Imaging guidance for percutaneous drainage with placement of catheter
76942	Ultrasonic guidance for needle placement
77011	CT guidance for stereotactic localization
77012	CT guidance for needle placement
77013	CT guidance for and monitoring of parenchymal tissue ablation
77021	MR guidance for needle placement
77022	MR guidance for and monitoring of parenchymal tissue ablation

Unlisted procedure codesCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional); used to report WBMRI
78999	Unlisted procedure, diagnostic nuclear medicine

Limited or follow-up CTCPT

76380

Limited or follow-up CT (used when full diagnostic code work not performed)

HCPCS codes and mapping noteHCPCS

S8042

MRI low field (example HCPCS code that should be redirected to specific CPT codes)

CT Myelogram/post-myelogram CT allowed codesCPTCovered

72126	CT Cervical post-myelogram (post-myelogram CT allowed)
72129	CT Thoracic post-myelogram
72132	CT Lumbar post-myelogram (post-myelogram CT allowed)

Post-myelogram CT / Post-discography CT guidanceCPTCovered

72131	CT Lumbar without contrast (Post-Discography CT) - allowed when verified as post-discography CT
72132	CT Lumbar with contrast (Post-Myelography CT)

Nuclear Medicine / Bone Scan / SPECT (Spondylolysis & Compression Fractures)CPTCovered

78803	Tomographic SPECT single area (CPT 78803) - Tomographic SPECT for localization
78831	SPECT minimum 2 areas single day or single area over 2+ days (alternate SPECT listing)
78830	SPECT/CT hybrid (CPT 78830)
78306	Whole body bone scan (CPT 78306)

Post-myelogram CT limitation noteCPT

72265	Other myelogram-related codes not permitted for approval under these guidelines (example - not allowed)
62284	Other myelogram-related codes not permitted for approval under these guidelines (example - not allowed)

Imaging guidance single unit rule (billing guidance)CPT

77012/77021/76942/77002/77003

Only one unit of guidance codes should be reported per individual encounter/date of service; the unit is the encounter not number of lesions

Spine PET/CT and PET-MRI stancemixed

78813	PET Whole-Body (PET/CT commonly used); unbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported
76498	MRI Unlisted for WBMRI or PET-MRI reporting as specified

Post-myelogram/post-discography coding and post-procedure CT guidanceCPTCovered

72131	CT Lumbar without contrast (post-discography CT allowed when discography approved)
72132	CT Myelogram Lumbar Spine (post-myelogram CT allowed)
72126	CT Cervical post-myelogram (allowed post-myelogram CT code)

SPECT / Bone Scan for preoperative or diagnostic useCPTCovered

78830	SPECT/CT hybrid used for localization and evaluation when indicated
78803	SPECT tomographic imaging for localization
78306	Whole body bone scan

Immediate post-vertebral augmentation imagingCPTCovered

72131

CT without contrast of affected spinal region within 24 hours post-procedure to evaluate cement extravasation sequelae (use appropriate CT code for region)

Key coding and billing constraints: only post-myelogram CT procedure codes (72126, 72129, 72132) are authorized for post-myelogram CT; do not unbundle PET/CT into separate PET and diagnostic CT codes; 3D rendering codes (76376/76377) must not be used for 2D reformatting and should not be billed with CAD, MRA, CTA, SPECT, PET, PET/CT, mammography, breast MRI/US, CT colonography, cardiac CT/MRI, or coronary CTA; guidance imaging codes (e.g., 77012, 77021, 76942, 77002/77003) are limited to a single unit per individual encounter/date of service; CPT 76380 (limited/follow-up CT) is not indicated for treatment planning or to cover extra slices; whole-body MRI is reportable using CPT 76498; and PET-MRI should be reported using CPT 78813 + CPT 76498 when appropriate and PET-CT is unavailable.

Provider Actions & Operational Requirements

Documentation Required

Submit adequate clinical information

Providers must submit adequate clinical information to establish medical necessity for spine advanced imaging. Required elements include: recent detailed history and physical examination (including a detailed neurologic exam), documentation of onset or change in symptoms, relevant laboratory results, and prior imaging. When an X-ray is required by the guideline, the plain radiographs must have been performed after the current episode of symptoms started or changed and results must be available to the requesting provider.

Required history and physical (recent detailed history; detailed neurologic exam)
Onset or change in symptoms documented
Relevant laboratory results when applicable
Prior imaging studies included
Plain X-rays performed after episode start/change with results available

Background & Evidence Summary

Background: These proprietary, evidence-based guidelines synthesize major society guidance (ACR, NASS, AAOS and others) and peer-reviewed literature to evaluate advanced imaging and procedures for adult spine conditions. The purpose is to ensure imaging is performed when it will affect clinical management, to define clinical documentation and pre-imaging requirements (including required in-person evaluation and plain X-rays when specified), and to reduce overutilization and unnecessary testing through standardized, condition-based criteria.

Evidence	Summary
{"text":"Conservative care effectiveness","status":""},{"text":"Multiple studies show most acute neck/back pain improves with a 6-week trial of conservative care (recommendation to require clinical re-evaluation after conservative therapy).","status":""}
{"text":"Early MRI and surgery risk","status":""},{"text":"Early MRI is associated with increased rates of surgery; studies cited report an ~eightfold increased risk of surgery with early MRI and increased utilization without improved outcomes."
status":""}
{"text":"Support sources","status":""},{"text":"Guideline references include ACR Appropriateness Criteria, NASS, AAOS, and peer-reviewed literature supporting modality selection and sequencing for spine imaging.","status":""}
{"text":"ACR Appropriateness Criteria references","status":""},{"text":"ACR Appropriateness Criteria (low back pain 2021 and other ACR guidelines) are cited as supporting sources for imaging recommendations.","status":""}
{"text":"Meta-analysis (Chou et al)","status":""},{"text":"Meta-analysis by Chou et al found no clinically significant difference in outcomes between immediate lumbar imaging versus usual care, supporting delayed imaging after conservative therapy.","status":""}
{"text":"Version","status":""},{"text":"V1.0.2025","status":""}

Definitions

Term	Definition
{"text":"Concurrent supervision (3D rendering)","status":""},{"text":"Active physician participation and monitoring of the 3D reconstruction process including design of anatomic region, tissue types to display, images to archive, and monitoring/adjustment of the 3D work product.","status":""}
{"text":"Radiculopathy","status":""},{"text":"Radicular pain in a specified dermatomal distribution with significant functional limitations plus one or more objective neurologic findings (altered sensation, motor weakness, reflex changes), or confirmatory EMG/ imaging within specified recency windows.","status":""}
{"text":"Radiculitis","status":""},{"text":"Radicular pain without objective neurological findings.","status":""}
{"text":"Red Flag Indications","status":""},{"text":"Clinical situations suggesting life- or limb-threatening conditions (motor weakness, cancer suspicion, infection, fracture, cauda equina, severe radicular pain) that warrant immediate advanced imaging and obviate conservative therapy requirement.","status":""}
{"text":"DISH","status":""},{"text":"Diffuse Idiopathic Skeletal Hyperostosis.","status":""}
{"text":"Post-myelogram CT","status":""},{"text":"CT performed after a myelogram; only specified CPT codes (72126, 72129, 72132) are authorized under these guidelines.","status":""}

Key Thresholds & Clinical Parameters

Operational thresholds

Conservative therapy trial6-week trial of provider-directed treatment with clinical re-evaluation (documented failure within 12 weeks)

Severe radicular pain thresholdMinimum 9/10 on VAS AND ≥7 days provider-directed treatment without response (plus functional loss and planned injection/surgery/referral)

Electrodiagnostic recencyEMG/NCS diagnostic for nerve root compression must be within prior 12 months

Neurologic exam recencyObjective neurologic findings (sensory/motor/reflex) must be within prior 3 months for radiculopathy criteria

Imaging timing for preopAdvanced imaging for preoperative planning should be performed within past 6 months

Imaging validity for injectionsMRI/CT showing severe spinal stenosis must be within prior 24 months for initial epidural steroid injection trial when criteria met

Revision History

02/01/2024annual update

Annual evidence-based update — Policy History notes annual evidence-based updates; no specific single clinical change highlighted.

07/01/2024interim update

Interim evidence-based update — Policy History notes an interim evidence-based update; no specific single clinical change highlighted.

05/01/2025annual updateLatest

Annual evidence-based update — Policy History notes annual evidence-based updates; no specific single clinical change highlighted.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Spine Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRADOI4OH.D

Change TypeAnnual and interim evidence-based updates (no material clinical change)

Effective DateNov 1, 2025

Next Review DateN/A

On This Page

MRI cervical spine is appropriate when there is a focal neurologic deficit, suspected ligamentous or cord injury, or when CT is nondiagnostic for soft tissue/cord pathology.

Consider MRI for neurologic signs or persistent neurologic symptoms.

Lower Extremity Pain with Neurological Features (Radiculopathy) / Low Back Trauma - Advanced Imaging Indications

Any one of the following supports advanced imaging for lower extremity radiculopathy or low back trauma when clinical features are present.

ANY of the following

Progressive or severe neurologic deficit (motor weakness, progressive sensory loss) referable to a lumbar nerve root or cauda equina syndrome features (saddle anesthesia, new urinary retention/incontinence, or significant bowel dysfunction).
Prioritize MRI lumbar spine with and without contrast if infection or neoplasm suspected; non-contrast MRI generally adequate for radiculopathy.
Radicular pain with objective neurologic findings (reproducible dermatomal sensory deficit, reflex change, or motor weakness) persisting despite 6 weeks of adequate conservative management (activity modification, NSAIDs/analgesics, physical therapy) or sooner if severe deficit present.
MRI lumbar spine without contrast appropriate for most radiculopathy indications; add contrast if prior surgery or concern for infection/neoplasm.
Acute low back trauma with high-risk features (e.g., major mechanism, neurologic deficit, suspicion of fracture) or inability to clear clinically.
CT may be preferred for suspected acute fracture; MRI for cord/soft tissue/ligamentous injury.
Lower extremity pain with neurological features and prior lumbar instrumentation where MRI with metal artifact reduction or CT myelography may be required.
Modality selection guided by prior surgery and suspected pathology.

Modality Substitution and Contrast Rules

All guidelines below apply to modality substitution, contrast use, and sequencing for spine imaging appropriateness.

ALL of the following

Modality selection
- MRI is the modality of choice for evaluation of neural elements, intervertebral discs, spinal cord, infection, neoplasm, and soft tissue pathology when no contraindication exists.
  Use MRI without contrast for routine radiculopathy; add IV contrast when infection, tumor, or post-operative scar differentiation is suspected.
- CT (non-contrast) is preferred for acute bony trauma and detailed osseous evaluation; consider CT with contrast for suspected vascular injury per protocol.
  CT is preferred if MRI contraindicated or unavailable.
- CT myelography is an alternative when MRI is contraindicated or nondiagnostic (e.g., severe hardware artifact), particularly to assess nerve root impingement.
  CT myelography requires lumbar puncture and is invasive; reserve when necessary.
Avoid routine use of IV contrast for spinal MRI in uncomplicated degenerative radiculopathy unless there is prior surgery, suspicion for infection, tumor, or when differentiating recurrent disc from scar.
When contrast is indicated, obtain MRI with and without contrast per clinical question.
Do not substitute radiographs for advanced imaging when MRI or CT is indicated for neurological deficits or high-risk trauma; radiographs may be used as initial screening in low-risk, nontraumatic presentations.
Plain radiographs are typically insufficient to evaluate neural compression or soft tissue/cord pathology.

Appropriateness and Sequencing of Imaging

All of the following general prerequisites should be satisfied before approval of advanced spinal imaging.

ALL of the following

A recent clinical evaluation (face-to-face or meaningful telehealth/telephone/electronic contact) documenting history, focused physical exam findings, and onset/change in symptoms relevant to the requested imaging.
If request is for routine scheduled surveillance (e.g., follow-up of known stable lesion), document prior baseline imaging and indication for surveillance.
Documentation of prior relevant imaging performed during the current episode of care (plain radiographs when indicated) and summary of conservative management measures attempted and their duration when applicable.
For radiculopathy, document at least 6 weeks of conservative care unless severe/progressive neurologic deficit or red flag present.
Clear clinical question or diagnostic uncertainty described that advanced imaging is intended to address (e.g., suspected fracture, infection, neoplasm, nerve root compression, cord compression, post-operative complication).
Requests lacking a specific clinical question are at risk for denial as unsupported.

General Requirement Before Advanced Imaging

All of the following general requirements must be met before obtaining advanced imaging when not emergent.

ALL of the following

Provider documents specific clinical indications and relevant exam findings supporting the requested advanced imaging modality and level(s).
Include dermatomal distribution, motor/reflex findings, and red flag symptoms if present.
When applicable, a trial of conservative therapy and documented response or nonresponse, including medications, physical therapy, activity modification, and duration.
Exceptions apply for progressive neurologic deficit, suspicion for serious pathology, or trauma per condition-specific guidance.
For post-operative or prior instrumentation cases, include operative report or summary and prior postoperative imaging to guide modality selection and interpretation.
Indicate presence and type of hardware; consider MRI with metal artifact reduction or CT as appropriate.

Red Flag Indications

Any of the following red-flag indications alone support urgent advanced imaging; suggested modality indicated in parentheses where applicable.

ANY of the following

Severe or progressive neurologic deficit (new motor weakness, rapidly progressive sensory loss).
Suggested modality: MRI spine without and with contrast when cord or soft tissue suspected; CT for acute bony injury.
Cauda equina syndrome signs (saddle anesthesia, new urinary retention or incontinence, severe bilateral leg weakness).
Suggested modality: urgent MRI lumbar spine without and with contrast as clinically indicated.
Suspected spinal infection (fever, elevated inflammatory markers, severe localized pain, recent bacteremia).
Suggested modality: MRI with and without contrast; consider nuclear medicine (FDG-PET) or labeled white cell studies in select cases.
Known or suspected spinal malignancy or metastasis (history of cancer with new/worsening spinal pain or neurologic signs).
Suggested modality: MRI with and without contrast; consider PET/CT or targeted CT for osseous detail.
Open or penetrating spinal trauma, or spinal instability with neurologic signs.
Suggested modality: CT cervical/thoracic/lumbar for bony injury; MRI for cord/ligamentous evaluation.

Definitions - Radiculopathy and Radiculitis

All of the following definitions are applied in the radiculopathy/radiculitis criteria.

ALL of the following

Radiculopathy: objective clinical evidence of nerve root dysfunction characterized by dermatomal distribution of sensory disturbance, focal reflex change, or motor weakness attributable to a specific nerve root.
Radiculopathy typically correlates with imaging findings of nerve root compression.
Radiculitis: subjective radicular pain consistent with a dermatomal distribution without objective neurologic deficit (normal strength and reflexes).
Radiculitis may warrant conservative care and imaging only if persistent or progressive per condition-specific guidance.

General Prerequisites Prior to Advanced Imaging

All prerequisites below should be documented prior to approval for advanced spinal imaging when applicable to the clinical presentation.

ALL of the following

Documented focused clinical evaluation within a timeframe relevant to symptom onset or change (face-to-face or equivalent), including neurological exam and red flag assessment.
If imaging is for routine surveillance, document baseline and indication for follow-up.
Prior plain radiographs of the affected spinal region when indicated by the guideline section (e.g., trauma screening, degenerative evaluation) or documentation explaining why radiographs are not appropriate or would not alter management.
Radiographs should be from the current episode of care.
Evidence of conservative management when applicable (e.g., at least 6 weeks for nonurgent radiculopathy) or documentation of reasons to proceed earlier (progressive deficit, red flag, or severe pain limiting function).
Include interventions tried and patient response.

Contraindication to MRI (documented implanted ferromagnetic materials, non-MRI-compatible electronic/mechanical devices).

Spinal trauma/fractures, especially those that could result in instability or cord/nerve compression.

Spinal neoplastic disease (primary or metastatic).

In conjunction with myelography or discography.

Preoperative evaluation to define abnormal or variant bony spinal anatomy.

Congenital, developmental or acquired spinal deformity.

Assessment of spinal fusions when pseudoarthrosis is suspected (not routine postoperative assessment without concordant signs/symptoms).

Spondylolysis when X-rays are negative and/or MRI is equivocal, indeterminate or nondiagnostic.

To evaluate calcified lesions (e.g., osteophytes, OPLL).

CT Myelography (SP-2.4) - indications and limits

CT Myelography guidance:

Generally unnecessary as an initial study when a diagnostic quality MRI has been obtained.

Indicated to clarify equivocal, indeterminate or non-diagnostic MRI findings or to further evaluate significance of multiple spinal abnormalities.

Indicated for preoperative planning when MRI is insufficient; indicated after prior spine surgery when MRI is contraindicated or equivocal/indeterminate.

Only post-myelogram CT procedure codes (CPT 72126, 72129, 72132) are allowed; other myelogram-related codes (e.g., 72265, 62284) are not permitted.

Imaging of Intervertebral Discs (SP-2.5)

Post-discography CT rules:

Post-lumbar discography CT is considered medically necessary following an approved discography and ALL of the following apply.

A CT Lumbar Spine without contrast (CPT 72131) is indicated if verified performed as a post-discography CT.

When a post-discography CT is requested and discography has already been approved, authorization will be issued for the post-discography CT procedure codes.

The guidelines allow only post-lumbar discography CT procedure codes and do not include other discography-related procedure codes.

Ultrasound of the Spinal Canal (SP-2.6)

Spinal canal ultrasound guidance:

Spinal canal ultrasound (CPT 76800) is primarily for newborns, infants, young children and intraoperative evaluation; CPT 76998 should be used for intraoperative ultrasonic guidance and does not require prior authorization.

CPT 76800 describes evaluation of the entire spine and should not be reported multiple times for different areas.

Indications: incomplete vertebral ossification for tethered cord evaluation; suspected occult/non-occult spinal dysraphism; assessment of CSF and image-guided lumbar puncture; evaluation of spinal cord tumors, vascular malformations and birth-related trauma.

Contraindicated for adult spine assessment of pain, radiculopathy, facet inflammation, nerve root inflammation, disc herniation, and deep soft tissue conditions (except superficial masses).

Limitations and general cautions (SP-2.7)

Limitations and cautions:

Advanced diagnostic imaging infrequently identifies the source of non-specific axial spinal pain; incidental findings are common and may lead to inappropriate treatment.

Performing advanced imaging based only on degenerative findings on X-rays is not generally indicated for asymptomatic individuals or those with non-specific axial pain.

If vertebral body hemangioma is typical on X-ray, no further advanced imaging is usually required unless neurologic symptoms/signs present.

Miscellaneous lesions and special modalities (SP-2.8 - SP-2.12)

Miscellaneous lesions and special modalities:

Tarlov cysts: usually incidental; further evaluation with MRI Lumbar Spine without and with contrast (CPT 72158) or CT myelography lumbar spine (CPT 72132) can be performed.

Other spinal lesions: MRI without and with contrast or CT without contrast is indicated if lesions seen on X-ray or non-contrast MRI and when required for surgical planning; recommended by spine specialist or radiologist.

MRA spinal canal: limited indications; may be used for suspected spinal vascular malformations; initial study should be MRI without and with contrast; catheter angiography recommended if high suspicion (CPT 72159 or 70496).

PET/CT: Spine PET/CT: considered not medically necessary for routine assessment of spinal disorders other than for neoplastic disease.

Cone-beam CT for cervical spine: considered not medically necessary.

3D rendering: see Musculoskeletal Imaging Guidelines (MS-3) for coding and indications.

Region-specific rules: Cervical, Thoracic, Lumbar (SP-3.1, SP-4.1, SP-5.1)

Common prerequisites and region-specific rules:

Common prerequisites for region-specific advanced imaging: In-person clinical evaluation performed; Failure of recent (within 12 weeks) 6-week trial of provider-directed treatment unless red flag present; Clinical re-evaluation after treatment period.6-week trial

Cervical specific: Results of plain X-rays of the cervical spine performed after the current episode started/changed need to be available; MRI Cervical without contrast (CPT 72141) OR CT Cervical without contrast (CPT 72125) if MRI contraindicated; exceptions for ankylosing spondylitis/DISH where whole spine MRI and CT can be approved without X-ray/6-week trial.

Thoracic specific: Results of plain X-rays of thoracic spine performed after current episode started/changed need to be available; MRI Thoracic without contrast (CPT 72146) OR CT Thoracic without contrast (CPT 72128) if MRI contraindicated; exceptions for ankylosing spondylitis/DISH.

Lumbar specific: Plain X-rays of the sacrum/coccyx should be negative for fracture (for coccydynia); MRI Lumbar Spine without contrast (CPT 72148) OR CT Lumbar Spine without contrast (CPT 72131) if MRI contraindicated; for coccydynia MRI Pelvis without contrast (CPT 72195) = CT Pelvis without contrast (CPT 72192) if MRI contraindicated.

trauma, spondylolysis, spondylolisthesis, spinal stenosis, SI joint, inflammatory spondylitis, compression fractures, syringomyelia, scoliosis/deformity, postoperative, preoperative, injections, SCS, vertebral augmentation, nuclear medicine sections (selected)

Indications by condition (selected sections):

Spondylolysis: When clinical suspicion high: Tomographic SPECT Planar (CPT 78803/78831) or SPECT/CT (CPT 78830/78832); Negative SPECT -> MRI lumbar without contrast (CPT 72148) OR CT lumbar without contrast (CPT 72131); Lesion on SPECT -> CT lumbar without contrast; Preoperative planning -> MRI and/or CT lumbar without contrast.

Repeat imaging not necessary for established non-healing pars defects

Spondylolisthesis: CT lumbar without contrast (CPT 72131) or MRI lumbar without contrast (CPT 72148) after plain X-ray for failure of 6-week conservative treatment, preoperative evaluation, or red flags.

Spinal Stenosis: MRI lumbar without contrast (CPT 72148) or CT lumbar without contrast (CPT 72131) indicated for clinical suspicion of lumbar spinal stenosis with red flags, failure of 6-week trial, or severe neurogenic claudication; CT myelogram (CPT 72132) may be considered for surgical planning when requested by operating surgeon.

SI joint / Inflammatory spondylitis: CT pelvis without contrast (CPT 72192) or MRI pelvis without contrast (CPT 72195) if plain X-rays equivocal AND one of: failure of 6 weeks conservative treatment, fractures, red flags, preoperative planning, suspicion of neoplastic/inflammatory/infectious disease; MRI pelvis without and with contrast (CPT 72197) for pediatric JIA.

Compression fractures: MRI without contrast; CT without contrast; or whole body bone scan (CPT 78306), SPECT (CPT 78803), or SPECT/CT (CPT 78830) after plain X-ray evaluation and concordant location when X-rays non-diagnostic and severe pain persists >1 week in predisposed individuals; surgical planning for kyphoplasty/vertebroplasty; indeterminate acuity on X-ray.

Syringomyelia: MRI cervical and thoracic spine without or without and with contrast (CPTs 72141/72156 and 72146/72157) and MRI brain without contrast (CPT 70551) when syrinx suspected or identified; include MRI lumbar to define extent.

Spinal deformity / scoliosis: After Cobb radiographs performed and available: MRI without/with contrast or CT/myelography for preoperative evaluation, congenital/atypical curves, left thoracic convexity, neurologic signs; CT angiography/MRA not routine for initial anterior surgery; CTA/MRA may be allowed for revision if requested by surgeon.

Postoperative: >6 months post-op: after plain X-rays, MRI without and with contrast, MRI without contrast, or CT without contrast if no significant improvement after recent 6-week trial; Within 6 months with prolonged intractable pain: MRI without and with contrast or CT without contrast/myelography if MRI contraindicated; imaging for surgical planning should be within past 6 months.6 months for preop imaging

Injections, SCS, vertebral augmentation, nuclear medicine: Imaging prior to injections: not required for facet/MBR/RFA unless criteria met; required within 24 months for cervical/thoracic injections when criteria met; for lumbar TFESI advanced imaging required when severe stenosis and other criteria met; SCS: MRI thoracic without contrast preferred (CPT 72146) or CT thoracic without contrast (CPT 72128) / CT myelography (CPT 72129); vertebral augmentation: CT without contrast within 24 hours post-procedure to evaluate cement extravasation; nuclear medicine: SPECT/CT or bone scan indications for implant loosening, failed fusion, suspected osteomyelitis, spondylolysis, and new symptomatic compression fractures when no malignancy.

3D rendering, cinematic rendering, or advanced 3D post-processing of spine imaging studies (including 3D reconstructions provided solely for visualization without demonstrated clinical impact on management) is not medically necessary.

Clinical use of experimental imaging sequences or proprietary post-processing algorithms for the spine that lack peer-reviewed evidence of improved health outcomes is not medically necessary.

Not Medically Necessary / Not Covered CPTCPTNot Covered

76390	CT/MR systemic/whole body 3-D rendering with interpretation and reporting
0609T	Magnetic resonance spectroscopy (MRS) head/neck/spine — single voxel (example procedure code series; apply per anatomic site as billed)
0610T	Magnetic resonance spectroscopy (MRS) head/neck/spine — multivoxel (example procedure code series; apply per anatomic site as billed)
0611T	Positional MRI (e.g., upright MRI) of spine; technical component
0612T	Positional MRI (e.g., upright MRI) of spine; professional component
72191	Magnetic resonance imaging, spinal canal and contents, lumbar; without contrast material(s) (Note: considered not covered when performed as weight-bearing/positional technique or with unproven advanced sequences)
72198	Magnetic resonance imaging, spinal canal and contents, lumbar; without and with contrast material(s) (Note: considered not covered when performed as weight-bearing/positional technique or with unproven advanced sequences)
74175	Computed tomography, abdomen and pelvis; with contrast material(s) (included here to represent CBCT/advanced CT-like 3D rendering situations when used for spine visualization rather than standard CT indications)
74185	Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sequences (included when advanced 3D rendering/CBCT is used for nonstandard spine visualization)
19085	Insertion of percutaneous peripheral catheter for interventional radiology, spine related (listed here to ensure representation; considered not covered when used with experimental imaging guidance techniques)

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Experimental / Investigational (Category III)CPTExperimental

0648T	MR spectroscopy, spinal — category III example code (investigational)
0649T	Positional MRI, spine — category III example code (investigational)
0697T	Cone-beam CT, spine — category III example code (investigational)
0698T	3D cinematic rendering, spine — category III example code (investigational)
0865T	Advanced 3D post-processing, spine — Category III (investigational)
0866T	Advanced 3D post-processing, spine — Category III (investigational)

Documentation Required

In-person clinical evaluation required

An in-person clinical evaluation for the current episode must be performed prior to consideration of advanced imaging (initial evaluation or clinical re-evaluation). Telemedicine, telephone, email, or other remote/meaningful contact do not satisfy the requirement for the initial in-person clinical evaluation.

Prior Authorization

6-week conservative therapy requirement

Most indications for advanced spinal imaging require documentation of a failed trial of conservative therapy consisting of a six-week course of provider-directed treatment. Clinical re-evaluation documenting failure of significant improvement must occur following that trial. Exceptions to the 6-week requirement include the presence of red flag indications (e.g., motor weakness, cauda equina, infection, fracture, cancer, severe radicular pain) in which conservative therapy is not required.

Trial length: six-week trial of provider-directed treatment
Re-evaluation window: clinical re-evaluation documenting failure of significant clinical improvement after the six-week trial (within the recent 12 weeks is referenced for timing)
Exceptions: red flag indications (motor weakness, cauda equina, infection, fracture, cancer, severe radicular pain) waive the conservative therapy requirement

Prior Authorization

Prior authorization may be required for 3D rendering codes

3D rendering CPT codes may require separate prior authorization and have specific billing restrictions. Affected codes include CPT 76376 and CPT 76377. These codes should not be used for routine 2D reformatting and have prohibitions on billing with certain modalities.

Affected codes: 76376, 76377

Billing Rule

Billing rules and coding limitations

Billing guidance and coding limitations for imaging and related services include unit and code-specific rules and prohibited pairings. Actionable billing points and affected codes are listed below.

Guidance codes: report only one unit per encounter for guidance codes (examples: 77012, 77021, 76942, 77002/77003) — unit of service = encounter/date of service
Do not bill 3D rendering for 2D reformatting: CPT 76376/76377 not to be used for 2D reformatting (2D reconstructions are included in base cross-sectional codes)
Do not unbundle PET/CT into separate PET and diagnostic CT CPT codes — PET/CT performed as a single study
Limited CT (CPT 76380) is not indicated for treatment planning and should not be used to cover extra slices
Post-myelogram CT: only CPT 72126, 72129, 72132 allowed for post-myelogram CT; other myelogram-related codes (e.g., 72265, 62284) are not permitted
CPT 76140 should be used for interpretation of outside studies (do not use diagnostic imaging codes for outside study interpretation)
Whole-body MRI: report using CPT 76498
WBMRI / PET‑MRI reporting: PET‑MRI when appropriate reported with CPT 78813 plus CPT 76498 per guidance

Documentation Required

Documentation requirements for CT vs MRI, X-rays, re-evaluation, and post-op conservative care

Document the clinical factors that support substitution of CT for MRI, plain radiograph results before advanced imaging, clinical re-evaluation after conservative therapy, and conservative care documentation for post-operative pain: provide specific evidence and items listed below as required.

Document MRI contraindications (e.g., implanted ferromagnetic materials, non‑MRI‑compatible electronic/mechanical devices) when requesting CT in place of MRI (affected codes examples: 72125, 72128, 72131)
Provide plain X-ray results performed after the current episode onset/change and make results available to the requesting provider prior to many advanced imaging requests
Clinical re-evaluation documentation after a 6-week conservative therapy trial (may be in-person or other meaningful contact) showing failure of significant improvement
For post-operative pain (>6 months post-op): document a recent (within 12 weeks) six‑week trial of provider‑directed treatment and clinical re-evaluation prior to advanced imaging requests
Post-discography CT: authorization for post-discography CT (e.g., CPT 72131) is issued only when discography has been approved

Prior Authorization

Prior authorization and timing requirements for specific imaging scenarios

Authorization and timing requirements for imaging and specific conditional authorizations are outlined below. Providers should secure prior authorization when the plan requires it and adhere to the specified timing and condition limits.

Pre-authorization: obtain prior authorization when required by the member's plan (general requirement noted throughout guideline)
Post-discography CT: authorization for post-discography CT (e.g., CPT 72131) will be issued only when discography has been approved
Preoperative planning timing: surgical planning imaging (MRI and/or CT) should have been performed within the past six (6) months
Epidural steroid injection for severe stenosis: MRI or CT (with or without myelography) demonstrating severe spinal stenosis at the level to be treated must have been performed within the prior 24 months to qualify for an initial trial of epidural steroid injection (per listed injection criteria)

High-risk fall definitionFall from elevation ≥ 3 feet / 5 stairs (listed as a high-risk factor for cervical spine injury)