CurrentUnitedHealthcarePolicy CSRAD014OH.E

Adult Spine Imaging Guidelines

UnitedHealthcare Community Plan evidence-based imaging guideline for adult spine imaging applicable only to Ohio; covers general imaging principles, modality-specific guidance (US, CT, MRI, PET), documentation requirements, investigational criteria, and coding/billing guidance for imaging and image-guided procedures. This is Part 1 of 6 and includes preface, general principles, and select CPT guidance.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Spine Imaging Guidelines

Policy CodePolicy CSRAD014OH.E

Change TypeAnnual evidence-based update

Effective DateFeb 3, 2026

Next Review Date

Key ActionProviders must submit detailed clinical evaluation since onset/change in symptoms (history, physical, labs, prior imaging) to establish medical necessity; spine/musculoskeletal requests require x-rays from the current episode.

POLICY UPDATE CHANGES

Annual evidence-based updates recorded on 11/06/2025; prior revisions include 05/01/2025, 07/01/2024, 02/01/2024.

164Document Pages (total)

V1.0.2026Guideline Version

Ohio-onlyGeographic Scope

6 weeksConservative treatment duration

one

Unit guidance codes allowed

Guideline Overview

This is the UnitedHealthcare evidence-based Adult Spine Imaging Guideline (Ohio only), Part 1 of 6, intended to guide appropriate imaging selection but not to replace clinical judgment. It is updated annually (next effective date shown here) and the effective date for this version is February 3, 2026. Scope: UnitedHealthcare Community Plan guideline for adult spine imaging in Ohio covering general principles, modality-specific guidance (US, CT, MRI, PET), documentation requirements, and coding/billing guidance for imaging and image-guided procedures.

Top-level key facts

Policy numberCSRAD014OH.E

Geographic scopeOhio-only

Conservative therapy duration6-week trial (failure documented)

Unit of guidance code allowed per encounterone

Guideline versionV1.0.2026

When Advanced Spine Imaging Is Medically Necessary

Application

Application (For Ohio Only): This Medical Policy applies to Ohio. Services listed as unproven or subject to coverage/quantity limits will be evaluated using Ohio Administrative Code 5160-1-01.

ALL of the following

Applies only to members and claims governed by the state of Ohio.
Unproven services and those with coverage or quantity limits will be reviewed for medical necessity in accordance with Ohio Administrative Code 5160-1-01.
Operational: Use OAC 5160-1-01 for determinations of investigational/unproven status and coverage limits for Ohio claims.

Clinical Documentation and Age Considerations

Clinical documentation and age considerations required prior to advanced imaging for adults.

ALL of the following

Condition-Specific Imaging Pathways and Criteria

Cervical Spine: Pain, Trauma, and High-risk Imaging Rules

Cervical spine condition-specific prerequisites, trauma guidance, and high-risk versus non-high-risk imaging rules (age and thresholds preserved).

Neck (Cervical Spine) Pain with/without Neurological Features - Prerequisites: All required prior to advanced imaging unless red flag: in-person clinical evaluation for current episode (initial or re-evaluation); failure of a 6-week trial of provider-directed treatment after current symptoms/exam started or changed; clinical re-evaluation after treatment period (may be in-person or other meaningful contact). MRI Cervical without contrast (CPT 72141) = CT Cervical without contrast (CPT 72125) OR CT myelography (CPT 72126) when MRI contraindicated.>= 6 weeks

Ankylosing spondylitis/DISH exceptions exist (see trauma section).

Neck (Cervical Spine) Trauma - Prerequisites and Imaging: All required prior to advanced imaging unless exceptions noted: in-person clinical evaluation; failure of a 6-week trial after symptoms/exam started or changed (unless red flag); clinical re-evaluation after treatment period; results of plain x-rays of cervical spine performed after current episode started or changed need to be available to requesting provider (not required for high-risk mechanisms). Advanced imaging options: MRI Cervical without contrast (CPT 72141) OR CT Cervical without contrast (CPT 72125) OR CT myelography (CPT 72126) when MRI contraindicated. For individuals with ankylosing spondylitis or DISH, both MRI of the entire spine AND CT of the entire spine are medically necessary and plain x-rays and 6-week trial/re-evaluation are NOT required.

CPT / Code Guidance and Examples

3D Rendering Codes (billing guidance)CPT

76376	3D rendering with interpretation and reporting; without image postprocessing on original acquisition
76377	3D rendering with interpretation and reporting; with image postprocessing on original acquisition

CT/MR/US Guidance Procedure Codes (examples table)CPTCovered

77011	CT guidance for needle placement; simple (e.g., spinal)
77012	CT guidance for needle placement; complex or multiple passes
77021	Magnetic resonance guidance for needle placement; breast
76942	Ultrasound guidance for needle placement

3D Rendering and Other Codes Not to be Billed Togethermixed

76376	Do not report with listed CT/MR/US modalities when policy prohibits concurrent billing
76377	Do not report with listed CT/MR/US modalities when policy prohibits concurrent billing

Unlisted / Limited CT/MR / Quantitative MRCPT

76498	Unlisted magnetic resonance procedure (use for whole-body MRI or other unlisted MR procedures)
72052	Radiologic examination, spine, single or multiple regions; limited

Spine MRI Procedure CodesCPTCovered

70540	MRI brain without contrast (included as reference where head/neck overlap applies)
70551	MRI brain with contrast (reference)
70552	MRI brain without and with contrast
72141	MRI cervical spine without contrast
72142	MRI cervical spine with contrast
72146	MRI thoracic spine without contrast
72147	MRI thoracic spine with contrast
72148	MRI lumbar spine without contrast
72149	MRI lumbar spine with contrast

Spine CT Procedure CodesCPTCovered

72125	CT cervical spine, without contrast
72126	CT cervical spine, with contrast
72127	CT cervical spine, without and with contrast
72131	CT thoracic spine, without contrast
72132	CT thoracic spine, with contrast
72133	CT thoracic spine, without and with contrast
72134	CT thoracolumbar w/o contrast (example)
72170	CT lumbar spine, without contrast
72171	CT lumbar spine, with contrast
72172	CT lumbar spine, without and with contrast

1–10 of 11

1/2

Nuclear Medicine Spine and Bone Procedure CodesCPT

78320	Bone imaging, whole body, planar imaging; initial whole-body imaging
78800	Whole-body PET imaging (example, modality reference)

Examples of referenced CPT codes (MR spine additional)CPT

72141	MRI cervical spine without contrast
72142	MRI cervical spine with contrast
72146	MRI thoracic spine without contrast
72147	MRI thoracic spine with contrast
72148	MRI lumbar spine without contrast
72149	MRI lumbar spine with contrast

Examples of referenced CPT codes (CT spine additional)CPT

72125	CT cervical spine, without contrast
72131	CT thoracic spine, without contrast
72170	CT lumbar spine, without contrast

Examples of referenced CPT codes (Guidance and Biopsy examples)CPT

19085	Breast, stereotactic, percutaneous, with placement of localization device, when performed (example contrasting biopsy guidance codes)
19086	Breast, stereotactic, with imaging and placement of localization device (example)
77021	Magnetic resonance guidance for needle placement; breast (contrast example)

Billing summary (concise): Guidance codes used for procedural guidance should be billed once per encounter; for diagnostic CT of the spine use the appropriate diagnostic CT CPT (e.g., 70486/72125 series) rather than CT-guidance-only codes like 77011. For image-guided breast biopsy examples, 19085/19086 are not interchangeable with 77021; select the appropriate biopsy or MR-guidance code. Do not report CPTs 76376 or 76377 with the listed CT/MR/US spine modality codes when the policy advises they are not to be billed together. Whole-body MRI reporting should use 76498 where an unlisted MR code is required. For post-myelogram or post-discography computed tomography, report the appropriate post-procedure CT spine code(s) as listed above and ensure documentation supports timing and clinical necessity. Preserve and reference CPT 70552 (MRI brain without and with contrast) where applicable in cases overlapping head/neck imaging.

Documentation, Prior Authorization, and Billing Actions

Documentation Required

Submit Pertinent Clinical Records

Providers must submit a detailed clinical evaluation since the onset or change in symptoms to establish medical necessity. Required documentation includes: history, physical examination, appropriate laboratory studies, and prior imaging. For spine and musculoskeletal requests, plain x-ray studies from when the current episode of symptoms started or changed must be provided to the requesting provider.

History
Physical examination (including detailed neurologic exam)
Appropriate laboratory studies
Prior imaging (plain x-rays for spine requests from current episode)

Documentation Required

In-person clinical evaluation required / Clinical re-evaluation after conservative therapy

Background, Evidence Basis, and Definitions

Evidence highlights and background: the guideline synthesizes evidence and major society sources (ACR Practice Parameters and ACR Appropriateness Criteria) and is aligned with those criteria. Key evidence points noted in the guideline include the FDA statement that gadolinium-based contrast agents are retained and require class warnings, ACR practice parameters/appropriateness criteria informing modality and contrast choices, literature showing most acute neck/back pain improves with a 6-week conservative trial, studies linking early MRI to increased rates of surgery and downstream utilization, and high rates of incidental MRI findings (e.g., thoracic spine). Recommendations are based on ACR criteria and the cited literature.

Key evidence metrics

FDA statement on GBCA retentionFDA warns GBCAs are retained and requires class warnings (2018)

ACR Practice Parameters referencedMultiple ACR practice parameters (MRI, CT, PET, Ultrasound) amended/amended 2023 referenced

Conservative care improvement intervalMost individuals improve with 6 weeks of conservative care

Risk of early MRIEarly MRI linked to increased surgery rates and higher downstream utilization (studies cited)

Document Revision Timeline

11/06/2025revisedLatest

Annual evidence-based updates recorded on 11/06/2025; prior revisions include 05/01/2025, 07/01/2024, 02/01/2024.

05/01/2025revised

Annual evidence-based updates recorded on 11/06/2025; prior revisions include 05/01/2025, 07/01/2024, 02/01/2024.

07/01/2024revised

Annual evidence-based updates recorded on 11/06/2025; prior revisions include 05/01/2025, 07/01/2024, 02/01/2024.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Spine Imaging Guidelines

Policy CodePolicy CSRAD014OH.E

Change TypeAnnual evidence-based update

Effective DateFeb 3, 2026

Next Review Date

On This Page

Provide a recent, condition-specific clinical evaluation since onset or change in symptoms, including detailed history and focused physical exam.

Include results of appropriate laboratory studies and prior imaging studies relevant to the current episode (spine and musculoskeletal guidelines require plain x-rays from the episode start/change).

Document the physician evaluation (face-to-face or documented telehealth/telephone/video/electronic contact) prior to ordering advanced imaging unless guideline supports scheduled surveillance.

For individuals ≤18 years follow Pediatric Imaging Guidelines where applicable; adults (>18 years) follow General/Adult Spine guidelines.

If request is for follow-up imaging in a guideline-supported scheduled surveillance, recent face-to-face evaluation may not be required; supply prior imaging and reason for surveillance.

Modality Selection Principles

Principles to guide modality selection for spine imaging.

ALL of the following

Select the imaging modality that best answers the clinical question with the least risk (radiation, contrast, cost) and greatest diagnostic yield.
Prefer MRI for evaluation of soft-tissue, neural element, infection, and malignancy unless contraindicated or CT is specifically indicated (e.g., acute fracture, bony detail, metal incompatible with MRI).
Prefer CT for high-resolution bony detail, acute trauma/fracture assessment, and when MRI is contraindicated or unavailable.
Use ultrasound selectively for superficial soft-tissue and vascular indications and for procedural guidance when not limited by bone.
Appropriate use of intravenous contrast (none, IV only, IV and oral/enteric) is determined by the specific clinical indication per condition-specific guidance.

CT vs MRI Substitution; CT without Contrast

CT versus MRI substitution rules and clinical scenarios where non-contrast CT is medically necessary.

ALL of the following

Use MRI in lieu of CT when MRI will provide the necessary diagnostic information (e.g., neural compression, infection, marrow involvement, malignancy staging) and there are no MRI contraindications.
CT may substitute for MRI when MRI is contraindicated, unavailable, or when the clinical question specifically requires superior bony resolution (e.g., fracture characterization, complex bony anatomy).
CT Without Contrast: Medically Necessary When ANY of the Following Apply
- Evaluation of acute osseous injury or fracture characterization where IV contrast is not required.
- Pre-procedural planning when bony landmarks and high-resolution bone detail are required and contrast provides no added value (e.g., certain surgical planning, hardware assessment).
- When MRI is contraindicated (e.g., certain implanted devices, patient intolerance, severe claustrophobia not managed by sedation) and the clinical question can be addressed by non-contrast CT.
- Assessment of acute hemorrhage or high-attenuation lesions where non-contrast CT better characterizes density than MRI.
Preserve AND/OR logic between substitution guidance and non-contrast CT indications.

Guidance and Localization Code Rules; Percutaneous Guidance

Guidance/localization codes, percutaneous guidance, and billing principles for CT/MR guidance and stereotactic localization.

ALL of the following

Guidance/localization codes (including stereotactic localization) are billed only when image guidance is performed and documented; documentation must describe the method of localization and guidance provided.
Percutaneous guidance codes (e.g., CT or MRI guidance for needle placement) are appropriate when guidance materially changes the procedure (trajectory planning, real-time imaging, confirmation of target) and should be supported by procedure notes describing the guidance steps and images obtained.
Do not report guidance/localization codes in duplicate with global procedure codes unless guidance is separate and distinct and meets coding rules for an additional service.
Use appropriate modifiers to indicate separate procedures when required by coding guidance; local payer billing rules may require prior authorization for guidance services.
Stereotactic localization codes apply when specific stereotactic localization techniques are used and must be documented; documentation should include localization method, targets, and how the information was used in the procedure.

Prerequisites Before Advanced Imaging (6-week Conservative Treatment)

Conditions required before advanced imaging of the spine is considered (conservative treatment prerequisites and thresholds).

ALL of the following

For non-emergent radicular or axial spine pain, advanced imaging is generally not appropriate until an adequate trial of conservative care and clinical reassessment has occurred unless red-flag indications (see Red Flag Indications) are present.
Conservative therapy trial: document at least 6 weeks of conservative management (e.g., activity modification, NSAIDs/analgesics, physical therapy, home exercise) unless a shorter or longer duration is clinically justified and documented.
Documentation must include type, duration, adherence, and clinical response to conservative measures prior to approval of routine advanced imaging for non-red-flag presentations.
Thresholds: default 6-week conservative care requirement for routine non-urgent imaging; exceptions detailed in Red Flag Indications.

Red Flag Indications (Exceptions to the 6-week Rule)

Red-flag indications that are exceptions to the conservative-treatment requirement and justify expedited or immediate advanced imaging.

ANY of the following

Motor Weakness
- Progressive or new focal motor weakness documented on exam (e.g., decreased strength in a myotomal distribution).
- Acute severe motor deficit with functional impairment.
Infection
- Clinical suspicion for spinal infection (e.g., fever, elevated inflammatory markers, recent bacteremia, paraspinal tenderness) requiring MRI with IV contrast to evaluate epidural abscess or vertebral osteomyelitis.
- Alternate phrasing: persistent fever, unexplained leukocytosis, elevated ESR/CRP with back pain and focal spinal tenderness — consider urgent MRI with IV contrast.
Cauda Equina Syndrome
- Saddle anesthesia, new bowel or bladder dysfunction, and severe or progressive bilateral lower extremity weakness or numbness — requires immediate MRI of the relevant spine region.
Fracture
- Acute traumatic mechanism with focal bony tenderness, neurologic deficit, or high-risk clinical features suggesting fracture — obtain urgent CT or MRI as indicated for fracture identification and stability assessment.
- Pathologic fracture suspected (e.g., minimal trauma in a patient with cancer or osteoporosis) — advanced imaging as clinically indicated.
Cancer
- Known or suspected metastatic disease with new or worsening back pain, focal neurological signs, or systemic signs suspicious for malignancy — MRI preferred for marrow and soft tissue assessment; consider PET/CT or whole-body imaging per condition-specific guidance.
- History of primary cancer with new focal back pain or neurologic symptoms — expedite MRI with IV contrast unless contraindicated.

High-risk factors where plain x-rays and 6-week trial are NOT required include: long term systemic glucocorticoids; prior low energy fractures; low bone mineral density; age >=65 years; head/maxillofacial trauma; pedestrian in MVA; fall from >=3 feet/5 stairs; diving accident; head-on MVA; rollover; ejection; high vehicle speed; not wearing seatbelt; minor trauma in AS/DISH.

Cervical Spine Injury - High-risk vs non-high-risk (excerpt): Imaging requirements differ by risk: Non-high-risk suspected fracture = plain x-rays are required for suspected fracture; High-risk suspected cervical spine injury within last 3 months = plain x-rays and a 6-week trial and clinical re-evaluation are NOT required when high-risk factors present (list includes age >=65 years and trauma thresholds).>= 65 years for age-related high risk; fall >= 3 feet / 5 stairs

Preserves differential imaging requirements by risk level.

Thoracic/Upper Back: Pain and Trauma Imaging Nodes

Thoracic (upper back) imaging prerequisites and trauma rules; modality substitution when MRI contraindicated preserved.

Upper Back (Thoracic Spine) Pain without/with Neurological Features (SP-4.1): All required prior to advanced imaging: in-person clinical evaluation for current episode; failure of a 6-week trial of provider-directed treatment after current symptoms/exam started or changed (unless red flag); clinical re-evaluation after treatment period; plain x-rays required for thoracic back pain without neurological features unless red flag present. MRI Thoracic Spine without contrast (CPT 72146) = CT Thoracic Spine without contrast (CPT 72128) OR CT myelography (CPT 72129) when MRI contraindicated.>= 6 weeks

Upper Back (Thoracic Spine) Trauma (SP-4.2): All required prior to advanced imaging: in-person clinical evaluation; failure of a 6-week trial (unless red flag); clinical re-evaluation after treatment period; conservative treatment and clinical re-evaluation not required in high-risk individuals (high-risk includes acute traumatic injury with midline thoracolumbar tenderness, high-energy mechanisms, or >60 years of age). After criteria met: MRI Thoracic Spine without contrast (CPT 72146) OR CT Thoracic Spine without contrast (CPT 72128). For AS/DISH, MRI of entire spine AND CT of entire spine are medically necessary and 6-week trial/re-evaluation are NOT required.> 60 years for thoracic/lumbar high risk

Modality alternative when MRI contraindicated preserved.

Lumbar/Lower Back: Pain, Trauma, Radiculopathy, and Severe Radicular Pain

Lumbar/lower back condition nodes including radiculopathy and severe radicular pain thresholds.

Low Back (Lumbar Spine) Pain without Neurological Features (SP-5.1): All required prior to advanced imaging: in-person clinical evaluation for current episode; failure of a 6-week trial of provider-directed treatment after current symptoms/exam started or changed (unless red flag); clinical re-evaluation after treatment period. MRI Lumbar Spine without contrast (CPT 72148) = CT Lumbar Spine without contrast (CPT 72131) OR CT myelography (CPT 72132) when MRI contraindicated.>= 6 weeks

Low Back (Lumbar Spine) Trauma (SP-6.2): All required prior to advanced imaging: in-person clinical evaluation; failure of a 6-week trial (unless red flag); clinical re-evaluation after treatment period; conservative treatment and re-evaluation not required in high-risk individuals (high-risk = acute traumatic injury with midline thoracolumbar tenderness, high-energy mechanisms, or >60 years). After criteria met: MRI Lumbar Spine without contrast (CPT 72148) OR CT Lumbar Spine without contrast (CPT 72131). For AS/DISH: whole-spine MRI AND CT are medically necessary and 6-week trial/re-evaluation not required.>= 6 weeks; > 60 years for high risk

Lower Extremity Pain with Neurological Features (Radiculopathy) (SP-6.1): All required prior to advanced imaging: in-person clinical evaluation; failure of a 6-week trial of provider-directed treatment after current symptoms/exam started or changed (unless red flag); clinical re-evaluation after treatment period. MRI Lumbar Spine without contrast (CPT 72148) = CT Lumbar spine without contrast (CPT 72131) OR CT myelography (CPT 72132) when MRI contraindicated. See Lumbar spinal stenosis guidance for related conditions.>= 6 weeks

Definitions of radiculopathy preserved in definitions section.

Severe Radicular Pain: Severe radicular pain meeting all of the following: minimum 9/10 VAS; documented significant functional loss at work or home; severity unresponsive to minimum 7 days of provider-directed treatment; treatment plan must include one of TFESI, cervical/thoracic ILESI, plan for urgent/emergent spinal surgery, or urgent/emergent referral to a spine specialist. Imaging options: MRI relevant spinal level without contrast OR MRI without and with contrast.>= 9/10 VAS; >= 7 days failed treatment

Treatment plan requirement explicit.

Specific Conditions: Myelopathy, Spondylolysis/Spondylolisthesis, Stenosis, SI Joint, Inflammatory Spondylitis, Fibromyalgia, Compression Fractures, Cancer

Specific condition nodes for myelopathy, pars defects, spondylolisthesis, spinal stenosis, SI joint/inflammatory spondylitis, fibromyalgia, compression fractures, and spinal pain related to cancer.

Myelopathy (SP-7.1): Advanced imaging is generally medically necessary in initial evaluation of documented or reasonably suspected myelopathy; x-rays are NOT required and conservative treatment is not required. MRI Cervical and Thoracic Spine without contrast, or without and with contrast, are medically necessary for evaluation of suspected myelopathy and specified neurologic findings; MRI Cervical, Thoracic, and Lumbar Spine without contrast (or without and with contrast) are medically necessary for suspected tethered cord/low-lying conus. CT without contrast or CT with contrast (myelography) can be considered when MRI contraindicated or for surgical planning.

X-rays not required regardless of prior surgery or trauma.

Spondylolysis (SP-8.1): Results of plain x-rays performed after current episode started/changed need to be available unless clinical suspicion is high. Clinical scenarios: if suspicion high = SPECT (CPT 78803/78831) OR SPECT/CT (CPT 78830/78832) (x-ray not required); negative SPECT -> MRI lumbar without contrast OR CT lumbar without contrast; lesion on SPECT -> CT lumbar without contrast; preoperative planning -> MRI and/or CT lumbar without contrast; failure of 6-week conservative treatment -> MRI or CT lumbar without contrast; evaluation for stress reaction or nerve roots -> MRI lumbar without contrast; if MRI contraindicated -> CT lumbar without contrast.>= 6 weeks for failed conservative treatment

Repeat imaging not necessary for established non-healable isthmic defect.

Spondylolisthesis (SP-8.2): CT lumbar without contrast (CPT 72131) or MRI lumbar without contrast (CPT 72148) can be considered after plain x-ray (performed after current episode started/changed and results available) for: failure of 6-week trial and clinical re-evaluation; preoperative evaluation; or red flag indications.>= 6 weeks

Lumbar Spinal Stenosis (SP-9.1): MRI lumbar without contrast (CPT 72148) or CT lumbar without contrast (CPT 72131) is medically necessary for clinical suspicion of lumbar spinal stenosis if: failure of 6-week trial and clinical re-evaluation; red flag indications; or severe neurogenic claudication restricting activity or requiring frequent narcotics. CT/myelogram (CPT 72132) may be considered for surgical planning when surgeon requests, especially multi-level stenosis.>= 6 weeks

Surgical planning note preserved.

Sacro-Iliac Joint Pain / Sacroiliitis (SP-10.1) and Inflammatory Spondylitis (SP-10.2): CT pelvis without contrast (CPT 72192) or MRI pelvis without contrast (CPT 72195) medically necessary if initial plain x-rays equivocal/not diagnostic AND failure of 6 weeks conservative treatment with re-evaluation, or any one of fractures of sacrum/SI joints, red flag indications, or pre-operative planning. For inflammatory spondylitis: plain x-rays required initially then MRI SI joints and MRI spine area of interest (with/without contrast depending on indication); CT pelvis without contrast is an alternative if MRI contraindicated; follow-up imaging options and AS/DISH exceptions preserved.>= 6 weeks

When plain x-rays and MRI of SI joints are negative, MRI spine area or CT spine area may be considered.

Fibromyalgia (SP-10.3): Advanced diagnostic imaging is not supported by the scientific evidence for the evaluation and treatment of fibromyalgia.

Spinal Compression Fractures (SP-11.1): After plain x-ray evaluation and concordant spinal pain location: MRI without contrast, CT without contrast, whole-body bone scan (CPT 78306), SPECT (CPT 78803), or SPECT/CT (CPT 78830) is medically necessary for any ONE of: x-rays reveal a new spinal compression fracture; x-rays non-diagnostic and severe spinal pain persists >1 week in individual predisposed to insufficiency fractures; age of fracture indeterminate on x-ray; surgical planning following known insufficiency fractures in candidates for kyphoplasty/vertebroplasty. For individuals with history of malignancy, refer to oncology-specific guidelines.> 1 week persistent severe pain in predisposed individuals

Spinal Pain related to Cancer (SP-12): For imaging in this setting, see Spinal/Vertebral Metastases (ONC-31.6) in the Oncology Imaging Guidelines.

Syringomyelia and Spinal Deformities/Scoliosis: Initial and Follow-up Imaging Rules

Syringomyelia initial and follow-up imaging rules and spinal deformity/scoliosis initial and revision imaging rules with pre-op CTA/MRA conditions.

Syringomyelia Initial Imaging Pathway (SP-13.1): MRI Cervical Spine without contrast (CPT 72141) and MRI Thoracic Spine without contrast (CPT 72146) medically necessary when syringomyelia is suspected. Once a syrinx is identified, MRI Brain without contrast (CPT 70551) AND MRI Cervical, Thoracic, and Lumbar Spine without (or without and with) contrast as needed to define extent are medically necessary if not already performed.

Syringomyelia Follow-up Imaging (SP-13.2): MRI Cervical Spine without contrast and MRI Brain without contrast and/or MRI Thoracic Spine when involved. If concern for malignancy, perform imaging without and with contrast. Annual imaging until non-progression established; following surgical treatment advanced imaging every three years for life can be performed once non-progression established; repeat imaging when neurologic deterioration occurs.annual until non-progression; every 3 years post-op once non-progression established

Spinal Deformities (Scoliosis/Kyphosis) (SP-14.1): MRI or CT/Myelography (if MRI contraindicated) of affected spinal regions medically necessary after plain radiographs (Cobb) have been performed and results available for pre-operative evaluation, congenital/atypical curves associated with cord pathology, neurologic signs/symptoms, or scoliosis with convex left thoracic curve. CT of affected regions (contrast as requested) is necessary for complex osseous deformity pre-op. CTA or MRA not medically necessary for preoperative planning for initial anterior spinal surgery.

Revision Anterior Spinal Deformity Surgery (SP-14.2): If requested by the operating surgeon for preoperative planning for revision of anterior thoracic or lumbar spinal surgery: CTA Pelvis (CPT 72191) OR CTA Abdomen (CPT 74175) OR CTA Abdomen and Pelvis (CPT 74174) OR MRA Pelvis (CPT 72198) and/or MRA Abdomen (CPT 74185) may be medically necessary.

Surgeon request required to justify CTA/MRA for revision planning.

Post-Operative Imaging: >6 Months, Within 6 Months, and Revision Planning

Post-operative imaging rules, thresholds for >6 months post-op and within-6-month urgent imaging, and allowed modality alternatives when MRI contraindicated.

Greater than Six Months Post-Operative (SP-15.1): Following plain x-rays of affected spinal regions post-surgical (performed after current episode started/changed with results available), MRI without and with contrast, MRI without contrast, or CT without contrast of affected spinal region(s) is medically necessary when: individual is > six months postoperative AND failure of a six-week trial of provider-directed treatment after current symptoms started/changed with clinical re-evaluation OR red flag indications. See Nuclear Medicine (SP-17) when MRI/CT nondiagnostic for suspected failed fusion.> 6 months post-operative; failure of 6-week trial

Plain x-rays post-surgical must be available to requesting provider.

Routine Post-Fusion Imaging (SP-15.2): Following a clinically successful spinal fusion, advanced diagnostic imaging is generally not medically necessary. PET is not medically necessary for routine assessment of spinal fusions or unsuccessful spine surgery.

Prolonged Intractable Pain Within Six Months Post-Surgery (SP-15.3): Following plain x-rays post-surgical with results available, MRI without and with contrast of affected spinal region(s) is medically necessary if there are residual, new, recurrent, or worsening symptoms related to the surgical spinal region within last 6 months. If MRI contraindicated, CT without contrast or CT with contrast (myelography) is medically necessary.within last 6 months

Revision Anterior Fusion Surgery Pre-Op Planning (SP-15.4): If requested by the operating surgeon, CTA Pelvis (CPT 72191) OR CTA Abdomen (CPT 74175) OR CTA Abdomen and Pelvis (CPT 74174) OR MRA Pelvis (CPT 72198) and/or MRA Abdomen (CPT 74185) may be medically necessary for pre-op planning prior to surgical revision of thoracic or lumbar anterior spinal arthrodesis.

Surgeon request required.

Pre-Procedural Imaging and Injection / SCS Planning (recency and documentation rules)

Pre-procedural imaging and injection/SCS planning rules including imaging recency windows and documentation requirements for surgeon-requested CTA/MRA.

Prior to Spine Surgery (SP-16.1): Advanced imaging needed for surgical planning (MRI and/or CT) should be performed within the past six (6) months when criteria for advanced imaging studies are met. MRA and CTA generally not medically necessary for pre-op planning of initial anterior spinal surgery unless abnormal vasculature is known or reasonably anticipated.within 6 months

Prior to Interventional Spinal Injections (SP-16.2): Advanced diagnostic imaging not required prior to facet joint injections, medial branch blocks, or radiofrequency ablations unless criteria met. Cervical/thoracic advanced imaging is medically necessary within 24 months prior to interlaminar or transforaminal epidural steroid injections when criteria met. Lumbar advanced imaging is medically necessary prior to transforaminal epidural steroid injections when criteria met; not required prior to lumbar interlaminar/caudal injections unless criteria met. For symptomatic spinal stenosis, MRI or CT (with/without myelography) demonstrating severe stenosis at level to be treated within past 24 months is required for initial trial of epidural injection when diagnostic evaluation rules out other causes, significant functional limitations present, and failure of at least 4 weeks of conservative treatment.24 months recency for cervical/thoracic injections; >=4 weeks failed conservative treatment for injection candidacy

Prior to Spinal Cord Stimulator Placement/Removal (SP-16.3): MRI Thoracic Spine without contrast (CPT 72146) is generally the study of choice prior to SCS placement. Acceptable alternatives when MRI contraindicated: CT Thoracic Spine without contrast (CPT 72128) OR CT/Myelography Thoracic Spine (CPT 72129). Imaging of the lumbar spine is not medically necessary for placement or removal of spinal cord stimulators.

Following Vertebral Augmentation Procedures (SP-16.4): CT without contrast of affected spinal region(s) within 24 hours post-procedure is medically necessary to evaluate neurologic sequelae from cement extravasation.within 24 hours

Nuclear Medicine Indications and Combination Rules

Nuclear medicine indications where bone scan/SPECT/SPECT-CT/Gallium/PET are medically necessary and combination rules.

Nuclear Medicine Indications (SP-17): Medically necessary nuclear medicine studies when x-ray/MRI/CT are non-diagnostic or for specific suspected diagnoses include: for suspected loosening of orthopedic implants when recent x-ray non-diagnostic = bone scan (CPT 78315) OR SPECT (CPT 78803/78831) OR SPECT/CT (CPT 78830); for back pain with suspected failed fusion and MRI/CT non-diagnostic = radiopharmaceutical localization SPECT (CPT 78803/78831) OR SPECT/CT (CPT 78830); for suspected spine osteomyelitis (initial or follow-up) = 3-phase bone scan (CPT 78315) OR bone SPECT (CPT 78803/78831) or SPECT/CT (CPT 78830/78832) OR Gallium whole-body or limited spine (CPT 78804/78801) OR Gallium SPECT/SPECT-CT; note any bone scan can be combined with any Gallium scan; FDG-PET/CT whole-body when x-ray or CT abnormal AND MRI cannot be performed or is inconclusive for suspected spine infection; for evaluation of facet arthropathy in AS/OA/RA = radiopharmaceutical localization inflammatory imaging or SPECT/SPECT-CT; for suspected spondylolysis = SPECT or SPECT/CT; for new symptomatic compression fracture without known malignancy = whole-body bone scan with add-on SPECT or SPECT/CT.

Select and document specific nuclear medicine CPT codes consistent with indication; bone + gallium combination allowed.

Initial evaluation for the current episode must be an in-person clinical evaluation documented by the provider. Advanced imaging generally requires clinical re-evaluation documenting failure of a six-week trial of provider-directed treatment; the re-evaluation may be in-person or other meaningful contact, but the initial evaluation must be face-to-face.

Initial clinical evaluation: must be in-person (history, physical, detailed neurologic exam)
Clinical re-evaluation after conservative therapy: document failure of a 6-week trial of provider-directed treatment (re-evaluation may be in-person or other meaningful contact)
Exceptions: red flag indications or specified high-risk conditions where the 6-week requirement does not apply

Prior Authorization

Prior Authorization for 3D Rendering Codes May Be Required

Prior authorization for 3D rendering codes may be required even when the underlying imaging does not require prior authorization. Applicable CPT codes are 76376 and 76377.

CPT 76376
CPT 76377

Billing Rule

Billing and Coding Rules for Guidance, 3D Rendering, Post-myelogram/post-discography CT, WBMRI, and Code Pairing

Billing rules and coding cautions described in the guideline include:

Do Not Bill Certain Codes Together: Do not report CPT 76376/76377 with CAD, MRA, CTA, SPECT, PET, PET/CT, stereotactic localization (77011/70486), mammogram, MRI breast, US breast, CT colonography, cardiac MRI/CT, or coronary CTA.
Single unit per encounter for guidance codes: Only one unit should be reported per encounter (date of service) for codes such as 77012, 77021, 77013, 77022, 76942, and 77002–77003.
Post-myelogram CT allowed codes: Approval allowed only for post-myelogram CT CPT codes 72126, 72129, and 72132 (myelogram procedure codes like 72265 or 62284 are not approved).
Post-discography CT coding: Post-lumbar discography CT must be coded as without contrast; CPT 72131 is the post-discography CT code when verified.
Whole-body MRI coding: Whole-body MRI should be reported only with CPT 76498; reporting WBMRI with multiple regional MRI codes or other methods is inappropriate.
Do Not Report CPT 77011 with Diagnostic CT: Do not report both CPT 70486 and CPT 77011 for the same CT stereotactic localization session; use 77011 when no radiologist interpretation is required and 70486 when interpreted.

Denial Risk

Investigational/Experimental Denial Risk

Requests for imaging or procedures considered investigational or experimental may be denied. Investigational determinations are based on any of the following: paucity of supporting evidence, evidence that has not demonstrated improved health outcomes, lack of demonstrated clinical utility, or lack of collective opinion of support.

Paucity of supporting evidence
Evidence has not matured to show improved health parameters
Clinical utility not demonstrated
Lack of collective opinion of support

Documentation Required

High-risk exceptions

When bypassing plain x-rays or the 6-week conservative therapy requirement for advanced imaging, providers must document high-risk features that justify the exception. High-risk features include ankylosing spondylitis or DISH, specified age thresholds, and specific trauma mechanisms and other listed clinical factors.

Ankylosing spondylitis (AS) or DISH — plain x-rays and 6-week trial are NOT required for AS/DISH in many trauma contexts
Age thresholds: ≥65 years for cervical high-risk; >60 years for thoracic/lumbar high-risk
High-risk trauma mechanisms: fall from ≥3 feet/5 stairs, diving accident, pedestrian struck, head-on/rollover/ejection, high-speed collision, not wearing seatbelt
Other high-risk factors: long-term systemic glucocorticoids, prior low-energy fractures, low bone mineral density, head or maxillofacial trauma

Imaging recency windows (summary): advanced imaging used for pre-operative planning should be performed within the past 6 months. Imaging prior to cervical or thoracic interlaminar/transforaminal epidural steroid injections should be available if performed within the prior 24 months. For certain procedures (e.g., vertebral augmentation) CT without contrast may be required within 24 hours post-procedure to evaluate for complications.

Risk of incidental MRI findingsAsymptomatic positive MRI findings reported up to 70% in thoracic spine studies

MRI sensitivity for L4-5 degenerative spondylolisthesis78% sensitivity (MRI) vs 98% for lateral standing films

Recommendation basisBased on ACR Appropriateness Criteria and literature reviews cited

Definitions (concise):

• Concurrent supervision (3D rendering): active physician participation and monitoring of 3D post-processing including anatomic design, tissue/structure selection, archive selection, and work product adjustment.

• Red Flag Indications: clinical situations suggesting life- or limb-threatening conditions that warrant exception to the six-week conservative therapy requirement (see Red Flag list).

• Radiculopathy: pain with significant functional limitation in a dermatomal distribution plus one or more objective findings (loss of strength, altered sensation, diminished/absent/asymmetric reflexes) or concordant imaging/electrodiagnostic evidence within prior 12 months.

• Radicular pain: pain radiating along a spinal nerve root distribution, typically from compression/inflammation/injury of the nerve root.

• Radiculitis: radicular pain without objective neurological findings.

• High-risk individuals: persons with features (age thresholds, high-energy mechanisms, midline tenderness, AS/DISH, specified trauma mechanisms) that permit bypassing plain x-rays or the 6-week conservative requirement.

• Conservative treatment: provider-directed non-advanced-imaging care for the current episode (e.g., education, activity modification, NSAIDs, analgesics, corticosteroids, home exercise, PT/OT, spinal manipulation, interventional pain procedures) attempted for 6 weeks unless red flag/high-risk present.

• Neurogenic claudication: leg/buttock pain worsened by walking/standing and relieved by sitting/flexion, suggestive of lumbar spinal stenosis.

• Spondylolysis: defect or fracture of the pars interarticularis often found incidentally on x-rays.

• Spondylolisthesis: forward or backward displacement of one vertebra relative to another.

02/01/2024revised

Annual evidence-based updates recorded on 11/06/2025; prior revisions include 05/01/2025, 07/01/2024, 02/01/2024.