CurrentUnitedHealthcarePolicy CSRAD014OH.D

Adult Spine Imaging Guidelines

UnitedHealthcare Community Plan evidence-based clinical guideline for adult spine imaging applicable only to Ohio members; defines appropriate use of advanced imaging modalities, documentation requirements, modality selection, and coding/billing considerations. This is Part 1 (preface and general guidance) of a multi-part guideline, effective Nov 1, 2025.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Spine Imaging Guidelines

Policy CodePolicy CSRAD014OH.D

Change TypeRevised (annual evidence-based update, v1.0.2025)

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionProvide recent detailed history, physical exam and prior imaging (including x-rays from current episode) when requesting advanced spine imaging.

POLICY UPDATE CHANGES

Annual evidence-based updates reflected in version v1.0.2025 with effective date November 1, 2025.

Part 1Document Part

V1.0.2025Version

MultipleCovered Indications

6 wksConservative Trial

6Preop Imaging Window (months)

InvestigationalQuantitative MR Analysis

Coverage Summary

This document is Part 1 of 6 of the UnitedHealthcare Community Plan Adult Spine Imaging Guidelines (Policy CSRAD014OH.D) and applies only to the state of Ohio. It is version V1.0.2025 with an effective date of November 1, 2025. The guideline series represents UnitedHealthcare proprietary, evidence-based clinical guidance for advanced imaging and related procedures and the coverage stance for this part is mixed (coverage with specific criteria and investigational exclusions). Key actionable requirements include documenting a recent in-person clinical evaluation and a documented 6‑week trial of provider‑directed conservative therapy (with clinical re-evaluation) prior to most advanced imaging unless a listed Red Flag Indication applies, and including required supporting documentation (history, focused neurologic exam, prior imaging/x-rays when required) when submitting requests or seeking authorization.

Quick-reference thresholds and timing

Failed conservative therapy trial6-week trial of provider-directed treatment with clinical re-evaluation documenting failure (trial must be recent — within 12 weeks)

Preoperative imaging recencyAdvanced imaging for surgical planning should be performed within 6 months prior to spine surgery

Imaging prior to cervical/thoracic injections look-backAdvanced imaging of cervical and/or thoracic spine required within 24 months prior to interlaminar or transforaminal epidural steroid injections when criteria met

Policy Summary

PayerUnitedHealthcare

PolicyAdult Spine Imaging Guidelines

Policy CodePolicy CSRAD014OH.D

Change TypeRevised (annual evidence-based update, v1.0.2025)

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionProvide recent detailed history, physical exam and prior imaging (including x-rays from current episode) when requesting advanced spine imaging.

On This Page

Medical-Necessity Criteria (Spine Imaging)

Application and Evidence Standards

This section applies to Ohio and describes document-level applicability and the evidence standards used to develop these spine imaging guidelines.

Application: This Medical Policy only applies to the state of Ohio. Any requests for services that are stated as unproven or services for which there is a coverage or quantity limit will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

Document scope: These evidence-based clinical guidelines evaluate advanced imaging and procedures for adult spine conditions including NM, US, CT, MRI, PET, and related interventions. They are intended to guide appropriate imaging selection, not to supersede clinical judgment.

Guideline development and review: Guidelines are based on current evidence supported by national/international society guidelines, peer-reviewed literature, major treatises, and input from practicing physicians. UnitedHealthcare reserves the right to update guidelines and they undergo formal review (at least annually).

Clinical documentation and evaluation standard: Pertinent clinical evaluation must be submitted and generally include a recent detailed history and physical exam since onset or change in symptoms, and prior imaging or laboratory studies when relevant. Advanced imaging should not be ordered prior to clinical evaluation by the treating clinician or appropriate consultant, except as noted for surveillance or guideline-supported follow-up.

X-ray prerequisite for spine/musculoskeletal guidelines: For spine and musculoskeletal guideline sections, plain radiographs (x-rays) from the time the current episode of symptoms started or changed are required when specified in the condition-specific sections. Failure to provide required prior x-rays may render advanced imaging requests not supported.

Evidence standards: Studies, procedures, or devices may be considered investigational/experimental/unproven when there is a paucity of supporting evidence, lack of demonstrated clinical utility, immature evidence without improved health outcomes, or absence of collective professional support. Supporting evidence includes well-conducted randomized trials, cohort studies with sufficient power, professional society recommendations, and collective clinical opinion when formal guidance is lacking.

Clinical trial and research imaging: Imaging requests for clinical trials will be evaluated against these evidence-based guidelines. Imaging inconsistent with established clinical standards or requested solely for data collection without impact on direct clinical management is not supported.

General Imaging Modality Guidance

Guidance for selection and use of imaging modalities, contrast administration, and rules for repeat imaging.

Modality selection principles: Choose the imaging modality that best answers the clinical question with the least risk and cost. Plain radiography, CT, MRI, and ultrasound are considered standard modalities; advanced modalities (e.g., PET, MR spectroscopy, positional MRI) are used when supported by condition-specific guidance.

MRI preference: MRI is preferred for evaluation of suspected soft tissue, neural element, spinal cord, marrow, infection, neoplasm, and most causes of radiculopathy or myelopathy when not contraindicated.

CT preference: CT is preferred for detailed osseous evaluation, acute fracture assessment when MRI unavailable or contraindicated, CT myelography when MRI is contraindicated or nondiagnostic for canal/nerve root assessment, and for post-operative hardware assessment when MRI is limited by artefact.

Ultrasound: Ultrasound is limited by bone and is generally not a primary modality for intraspinal evaluation. It may be used for superficial soft-tissue or paraspinal evaluations and certain procedure guidance when appropriate and operator expertise exists.

3D Rendering (CPT 76376, 76377) Criteria

Criteria for 3D rendering (CPT 76376, 76377) including clinical scenarios and billing constraints.

3D rendering (CPT 76376, 76377) is considered an adjunct to diagnostic CT or MRI and is covered only when it provides additional clinically relevant information that changes management beyond standard multiplanar reformats.

ANY of the following

Preoperative surgical planning for complex spinal deformity, tumor resection involving bony anatomy, or complex fracture patterns where 3D visualization alters surgical approach.
Vascular workup in spinal vascular malformations or preoperative evaluation where 3D surface or volume-rendered images assist endovascular or surgical planning.
When conventional reformats are inadequate to depict complex anatomy or hardware relationships and a 3D rendering provides unique visualization impacting patient care.

Imaging Guidance Codes (CT/MR/US-guided procedures)

Rules for image-guided procedures and reporting of guidance codes.

Guidance code rules: Codes for image guidance (CT/MR/US-guided procedures) are billable when guidance is required for needle or device placement and meet CPT definitions. Guidance codes should reflect the modality used and the documented procedural need.

Unit-of-service: Image guidance is billed per service episode consistent with CPT guidelines; multiple guidance units require documentation of separate, distinct services or separate levels/targets as defined by CPT.

Pairing constraints and exclusions: Guidance codes that are integral to the imaging study or procedure may be bundled and not separately payable. Documentation must demonstrate that the guidance was an additional, distinct service when billed separately. Guidance codes are not payable when imaging is solely diagnostic and no procedural guidance was provided.

Prerequisites for Advanced Diagnostic Imaging

Prerequisites that must all be met before advanced diagnostic imaging of the spine is supported.

ALL of the following

An in-person or meaningful technological clinical evaluation (telehealth, telephone, or electronic messaging) by a treating clinician since onset or change in symptoms, with documentation of history and focused physical examination findings.
A trial of conservative therapy appropriate to the condition (e.g., activity modification, analgesics, physical therapy) unless there is a red flag indication or clinician documents why conservative therapy is not appropriate or was contraindicated.
A focused neurologic examination documenting motor, sensory, and reflex findings when neurologic symptoms are present.
When specified in condition-specific sections, recent plain radiographs (x-rays) from the time the current episode of symptoms started or changed have been obtained and reviewed unless contraindicated or clinically unnecessary (e.g., acute severe neurologic deficit requiring immediate advanced imaging).

Red Flag Indications

Red flag indications that warrant expedited imaging. ANY of the following life- or limb-threatening conditions support immediate advanced imaging with the modality indicated.

ANY of the following

Motor weakness: New or progressive motor weakness (e.g., significant paresis) — urgent MRI of the appropriate spinal region is indicated.
Cauda equina syndrome: Signs or symptoms of cauda equina syndrome (saddle anesthesia, new bowel or bladder dysfunction, severe/progressive bilateral lower extremity weakness) — urgent MRI of the lumbar spine (with or without contrast as clinically indicated) or CT myelography if MRI is contraindicated.
Spinal infection: Suspected epidural or vertebral osteomyelitis (fever, back pain, elevated inflammatory markers, recent infection or bacteremia) — MRI with contrast of the appropriate spinal region is preferred; contrast-enhanced CT if MRI contraindicated.

Spinal Infection Imaging (excerpt)

Spinal infection imaging considerations (excerpt).

Suspected spinal infection: MRI with intravenous contrast is the preferred study to evaluate for vertebral osteomyelitis, discitis, epidural abscess, or paraspinal infection. If MRI is contraindicated or unavailable, contrast-enhanced CT is an acceptable alternative. Nuclear medicine (e.g., tagged WBC or FDG PET/CT) may be considered when MRI/CT are nondiagnostic or contraindicated and clinical suspicion remains high.

Severe Radicular Pain

Criteria for imaging in severe radicular pain.

Severe radicular pain: Imaging is supported when the patient has severe, intractable radicular pain that is not relieved by appropriate conservative measures and significantly limits activities of daily living or sleep, or when there is progressive neurologic deficit. MRI of the symptomatic spinal region is preferred; CT myelography if MRI is contraindicated.

Radiculopathy definition (SP-1.3)

Definition of radiculopathy used in the guideline.

Radiculopathy definition (SP-1.3): Radiculopathy refers to objective neurologic impairment attributable to nerve root irritation or compression, typically manifesting as dermatomal sensory loss, myotomal weakness, diminished reflexes in the distribution of a specific nerve root, and/or electrodiagnostic findings consistent with radicular involvement.

MRI of the Spine Indications (SP-2.2)

Indications for MRI of the spine.

MRI of the Spine Indications (SP-2.2): MRI is indicated for suspected infection, neoplasm, acute neurologic deficit (motor weakness, cauda equina, myelopathy), persistent or progressive radiculopathy after conservative care, preoperative planning for decompression or fusion when neural elements must be assessed, and for evaluation of spinal cord or canal pathology.

CT of the Spine Indications (SP-2.3)

Indications for CT of the spine.

CT of the Spine Indications (SP-2.3): CT is indicated for acute trauma with suspected fracture, osseous detail for surgical planning, evaluation of complex degenerative changes when MRI contraindicated or insufficient for bony detail, and when CT-guided procedures are planned.

CT/Myelography Indications (SP-2.4)

Indications for CT myelography.

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Post-lumbar Discography CT (SP-2.5)

Indications and constraints for post-lumbar discography with CT.

Post-lumbar Discography CT (SP-2.5): Post-discography CT may be indicated to correlate annular disruption with provoked symptoms when considered for surgical planning and when other noninvasive imaging is nondiagnostic. Discography and post-discography CT are invasive tests with limited indications and require thorough documentation of prior noninvasive imaging and clinical correlation.

MR Spectroscopy and Positional MRI

Guidance regarding MR spectroscopy and positional MRI.

MR Spectroscopy and Positional MRI: MR spectroscopy and positional (dynamic/weight-bearing) MRI are considered specialized techniques and are supported only when there is specific evidence that the modality will provide diagnostic information not obtainable by conventional MRI and will change management. These studies are generally considered adjunctive and require clear justification.

Ultrasound of the Spinal Canal (SP-2.6)

Ultrasound use in spinal canal and paraspinal evaluation.

Ultrasound of the Spinal Canal (SP-2.6): Ultrasound is limited for intraspinal evaluation due to bone obstruction. It may be used for superficial paraspinal soft tissue assessment, for guidance of superficial injections, or in pediatric neonates for open fontanelles/spinal dysraphism assessment under specific circumstances. Operator experience and documentation of diagnostic yield are required.

Limitations in Degenerative Disorders (SP-2.7)

Limitations of imaging in degenerative disorders.

Limitations in Degenerative Disorders (SP-2.7): Imaging findings of degenerative change (disc bulge, spondylosis, foraminal narrowing) are common and may not correlate with symptoms. Advanced imaging for degenerative findings is supported when there are corresponding clinical findings (e.g., progressive neurologic deficit, radiculopathy consistent with imaging findings) or when imaging is needed for procedural planning. Routine imaging for chronic, stable degenerative symptoms without red flags is not supported within short intervals.

MR Spectroscopy and Positional MRI

Guidance on miscellaneous spinal lesions and less common modalities.

Miscellaneous Spinal Lesions (SP-2.8): For uncommon spinal lesions (e.g., vascular malformations, rare tumors), imaging selection should be individualized and justified by clinical presentation. Advanced modalities (MRA, PET/CT, specialized MRI sequences) are supported when likely to provide incremental diagnostic information impacting management.

MRA Spinal Canal (SP-2.9): Spinal MRA may be indicated for evaluation of suspected spinal vascular malformations or aneurysms related to spinal pathology; selection of contrast-enhanced techniques follows standard vascular imaging indications.

Spine PET/CT (SP-2.10): PET/CT is primarily useful for evaluation of metastatic disease, infection in select scenarios, and when conventional imaging is inconclusive; use should be guided by oncologic context and prior imaging results.

Cone-beam CT (SP-2.11): Cone-beam CT may be used intraoperatively or for localized high-resolution bony assessment in select settings; billing and documentation must reflect the clinical necessity and limitations compared with conventional CT.

Neck (Cervical Spine) Pain without and with Neurological Features (SP-3.1)

Neck (Cervical Spine) pain criteria for imaging without and with neurological features, including stenosis and trauma.

ANY of the following

Acute neck pain without neurologic signs or red flags: initial plain radiographs may be appropriate for trauma or if fracture suspected. Advanced imaging (CT or MRI) is not routinely supported for uncomplicated neck pain without neurologic findings unless symptoms persist after appropriate conservative therapy or other specific indications exist.
Chronic or persistent neck pain without neurologic deficit: Advanced imaging may be considered after a trial of conservative management and when plain radiography (if indicated) has been performed; MRI is preferred when localized pathology (e.g., suspected disc herniation, facet arthropathy) is suspected and correlates with clinical findings.

ANY of the following

Neck pain with radiculopathy (cervical radiculopathy) or myelopathic signs (gait disturbance, hand clumsiness, hyperreflexia): MRI of the cervical spine is indicated to evaluate nerve roots and spinal cord. If MRI is contraindicated, CT myelography is an alternative.

Medical-Necessity Criteria (Spine Imaging)

Upper back (thoracic spine) pain criteria for imaging without and with neurological features, including stenosis and trauma.

ANY of the following

Isolated thoracic back pain without neurologic findings or red flags: initial conservative management is recommended. Plain radiographs may be appropriate when fracture, structural deformity, or significant trauma is suspected. Advanced imaging (MRI/CT) is not routinely supported for uncomplicated thoracic pain without neurologic features unless symptoms persist or other clinical indications emerge.
Persistent or focal thoracic pain after conservative therapy or with suspicion for localized pathology (e.g., suspected tumor, infection, focal osteomyelitis): MRI with contrast is preferred; CT is an alternative when MRI contraindicated.

ANY of the following

Thoracic radiculopathy, myelopathy, or suspected spinal cord compression: MRI of the thoracic spine (with contrast as indicated) is recommended to assess cord and root involvement. Urgent MRI is indicated for progressive neurologic deficits.

Condition-Specific Indications (Neck, Thoracic, Lumbar, Postoperative, Deformity, Nuclear Medicine)

Neck/Thoracic/Lumbar Condition-specific Sections (SP-3 to SP-6)

Condition-specific prerequisites and imaging choices for neck, thoracic, lumbar, coccydynia, lower extremity radicular pain and trauma sections.

Neck Pain (SP-3.1) prerequisites and imaging: All required prior to advanced imaging: in-person clinical evaluation for current episode; failure of recent (within 12 weeks) 6-week trial of provider-directed treatment unless red flag; clinical re-evaluation after treatment. Imaging: MRI cervical without contrast (CPT 72141) OR CT cervical without contrast (CPT 72125) OR CT myelography (CPT 72126) when MRI contraindicated.6-week trial within 12 weeks

Neck Trauma (SP-3.2) prerequisites and exceptions: All required: in-person evaluation, 6-week conservative trial failure unless red flag, clinical re-evaluation, and plain x-rays of cervical spine after current episode must be available unless high-risk mechanism. Imaging: MRI cervical without contrast (CPT 72141) OR CT cervical without contrast (CPT 72125). For ankylosing spondylitis/DISH, whole-spine MRI and CT can be approved and x-rays/6-week trial not required.

High-risk factors listed in policy section.

Upper Back Thoracic Pain (SP-4.1) prerequisites: All required: in-person evaluation, failure of 6-week trial within 12 weeks unless red flag, and clinical re-evaluation. Imaging: MRI thoracic without contrast (CPT 72146) OR CT thoracic without contrast (CPT 72128) when MRI contraindicated.6-week trial

Thoracic Trauma (SP-4.2) prerequisites: All required: in-person evaluation, failure of 6-week trial unless red flag, clinical re-evaluation, and plain x-rays of thoracic spine performed after current episode must be available. Imaging: MRI thoracic without contrast (CPT 72146) OR CT thoracic without contrast (CPT 72128). Ankylosing spondylitis/DISH exceptions allow whole-spine MRI/CT and waive x-ray/6-week requirements.

Low Back Lumbar Pain (SP-5.1) prerequisites and imaging: All required: in-person evaluation, failure of 6-week trial within 12 weeks unless red flag, clinical re-evaluation. Imaging: MRI lumbar without contrast (CPT 72148) OR CT lumbar without contrast (CPT 72131) OR CT myelography (CPT 72132) when MRI contraindicated.6-week trial

Coccydynia (SP-5.2) prerequisites: All required: in-person evaluation, failure of 6-week trial unless red flag, clinical re-evaluation, and plain x-rays of sacrum/coccyx negative for fracture. Imaging: MRI pelvis without contrast (CPT 72195) OR CT pelvis without contrast (CPT 72192) if MRI contraindicated.6-week trial

Lower Extremity Pain with Neurological Features (SP-6.1): All required: in-person evaluation, failure of 6-week trial within 12 weeks unless red flag, clinical re-evaluation. Imaging: MRI lumbar without contrast (CPT 72148) OR CT lumbar without contrast (CPT 72131) OR CT myelography (CPT 72132) when MRI contraindicated. Note: plain x-rays may be required per section; hip/pelvis imaging not generally required unless separate indication.6-week trial

Definitions of radiculopathy per SP-1.3.

Low Back Trauma (SP-6.2) prerequisites: All required: in-person evaluation, failure of 6-week trial unless red flag, clinical re-evaluation, and plain x-rays of lumbar spine performed after current episode must be available. Imaging options include MRI lumbar without contrast (CPT 72148), MRI lumbar without and with contrast (CPT 72158), CT lumbar without contrast (CPT 72131), or CT myelogram (CPT 72132).

Ankylosing spondylitis/DISH exceptions noted.

Myelopathy, Spondylolysis/Spondylolisthesis, Lumbar Stenosis

Myelopathy, spondylolysis/spondylolisthesis, and lumbar spinal stenosis imaging logic and exceptions.

Myelopathy (SP-7.1) prerequisites and indications: Advanced imaging is generally indicated in initial evaluation of documented or suspected myelopathy; x-rays are not required and conservative treatment is not required. MRI cervical and/or thoracic without contrast or without and with contrast indicated for suspected myelopathy, post-traumatic syrinx with worsening symptoms, sustained unexplained Lhermitte's, unexplained Babinski/Hoffmann's/hyperreflexia/bilateral motor weakness. MRI cervical/thoracic/lumbar indicated for suspected tethered cord/low lying conus. CT (with or without myelography) can be an alternative when MRI contraindicated or in addition to MRI for surgical planning.

Spondylolysis (SP-8.1) imaging selection: When clinical suspicion high: SPECT planar (CPT 78803/78831) or SPECT/CT (CPT 78830/78832) (x-ray not required). If SPECT negative: 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. Failure of 6-week conservative treatment with re-evaluation -> MRI lumbar without contrast OR CT lumbar without contrast. MRI may be less sensitive for pars defects; CT useful to evaluate bony anatomy and healing potential.

Repeat imaging not necessary for established non-union without healing potential.

SI Joint Pain, Inflammatory Spondylitis, Fibromyalgia

SI joint, inflammatory spondylitis, and fibromyalgia coverage stances and indications.

Sacro-Iliac (SI) Joint Pain / Sacroiliitis (SP-10.1): CT pelvis without contrast (CPT 72192) or MRI pelvis without contrast (CPT 72195) indicated when initial plain x-rays are equivocal/not diagnostic AND failure of 6 weeks provider-directed treatment with clinical re-evaluation OR any ONE of: sacral/SI fractures, red flag indications, preoperative planning. Pediatric JIA or suspicion of infection/inflammation/neoplasm -> MRI pelvis without and with contrast (CPT 72197); CT pelvis without contrast when MRI contraindicated.6-week trial

Inflammatory Spondylitis (SP-10.2): When plain x-rays equivocal/not diagnostic -> MRI (with or without contrast) of affected spinal region; CT without contrast if MRI contraindicated. Follow-up imaging for treatment response/progression may include MRI pelvis (SI joints) and MRI spine combinations as detailed. For documented ankylosing spondylitis/DISH and spine pain after trauma, plain x-rays not required prior to advanced imaging.

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

Compression Fractures, Cancer-related Pain, Syringomyelia, Spinal Deformities

When imaging is indicated for compression fractures, cancer-related spinal pain, syringomyelia, and spinal deformities.

Spinal Compression Fractures (SP-11.1): After plain x-ray and concordant pain location, individuals without malignancy: MRI without contrast, CT without contrast, or whole body bone scan (CPT 78306) OR SPECT (CPT 78803) OR SPECT/CT (CPT 78830) indicated for any ONE: x-ray reveals new compression fracture; x-rays nondiagnostic and severe pain persists >1 week in someone predisposed to insufficiency fractures; deformity acuity indeterminate on x-ray; surgical planning for vertebral augmentation candidates. For history of malignancy, refer to oncology metastases guidelines.

Spinal Pain related to Cancer (SP-12): Cross-reference to Spinal/Vertebral Metastases (ONC-31.6) for imaging recommendations when cancer-related spinal pain suspected.

Syringomyelia (SP-13.1 / SP-13.2): When syringomyelia suspected: MRI cervical and thoracic spine without contrast or without and with contrast (CPT 72141/72156; 72146/72157). Once a syrinx identified: MRI brain without contrast (CPT 70551) AND MRI cervical/thoracic/lumbar as needed to define extent; follow-up imaging: MRI brain and spine per section with annual imaging until non-progression established and then every 3 years after surgical treatment; repeat imaging with neurologic deterioration.

Postoperative/Pre-op/Interventional Imaging Requirements and Timing

Postoperative imaging, preoperative timing thresholds, and imaging requirements prior to injections, SCS, and post-augmentation.

Postoperative Spine Imaging (SP-15): Greater than six months post-op: after plain x-rays with results available, MRI (with/without contrast), MRI without contrast, or CT without contrast of affected region indicated when ANY: >6 months post-op AND no significant improvement after recent (within 12 weeks) six-week trial of provider-directed treatment with re-evaluation; or red flag indications. Routine post-fusion imaging generally not indicated after clinically successful fusion; PET not indicated for routine assessment.>6 months post-op; 6-week conservative trial within 12 weeks

Use nuclear medicine when MRI/CT nondiagnostic for suspected failed fusion.

Prolonged intractable pain within 6 months: Within six months post-surgery with prolonged intractable pain: after plain x-rays with results available, MRI without and with contrast indicated for residual/new/recurrent/worsening symptoms related to surgical site; CT without contrast or CT with myelography if MRI contraindicated.<6 months post-op

Nuclear Medicine — Indications (SP-17)

Nuclear medicine indications including SPECT/SPECT-CT, bone scan and when nuclear imaging is preferred/allowed.

Nuclear Medicine — Indications (SP-17): Indicated studies when plain x-ray or MRI/CT are nondiagnostic or for specific contexts: for suspected implant loosening when recent x-ray nondiagnostic -> bone scan (CPT 78315) OR SPECT (CPT 78803/78831) OR SPECT/CT (CPT 78830/78832). For back pain with suspected failed fusion and nondiagnostic MRI/CT -> SPECT (CPT 78803/78831) OR SPECT/CT (CPT 78830). For suspected osteomyelitis -> bone scan (CPT 78300/78305/78306/78315) OR SPECT (CPT 78803) OR bone marrow imaging (CPT 78102/78103/78104) OR radiopharmaceutical inflammatory imaging (CPT 78800/78801/78802). For suspected spondylolysis or radiographically occult fractures -> SPECT (CPT 78803/78831) or SPECT/CT (CPT 78830/78832). For new symptomatic compression fracture without malignancy -> whole body bone scan with SPECT add-on (CPT 78803) or SPECT/CT (CPT 78830).

Appropriate follow-up timeframe depends on disease and prior imaging.

Coding

Spine MRI Procedure CodesCPTCovered

72148	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without contrast material
72149	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; with contrast material(s)
72150	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without and with contrast material(s)
72156	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material
72157	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; with contrast material(s)
72158	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without and with contrast material(s)
72195	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material
72196	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; with contrast material(s)
72197	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without and with contrast material(s)
72192	Magnetic resonance, any site of spine, without contrast, including T1, T2, multisequence; cervical, thoracic, or lumbar (alternate code referenced in source)

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Quantitative MR Analysis CodesCPTExperimental

76499	Unlisted radiology procedure (used for quantitative MR analysis when no specific code applies)
76390	Magnetic resonance guidance for needle placement (when applicable to quantitative analysis workflow)

MR Spectroscopy (Not Medically Necessary)CPTNot Covered

76390-XS	Example modifier pairing when spectroscopy not covered (placeholder)
77058	MR spectroscopy (not covered per guideline) - example coding note

Unlisted CT/MR and Limited CT CodesCPT

76498	Unlisted magnetic resonance procedure (use for whole-body MRI or other unlisted MR procedures when appropriately documented)
76499	Unlisted radiology procedure (CT/MR)

Nuclear Medicine / PET-MRI Related CodesmixedCovered

78813	Positron emission tomography (PET) with concurrently acquired CT for attenuation correction and anatomic localization; single area or whole body
76498	Unlisted magnetic resonance procedure (used to report whole-body MRI when applicable)

Guidance and Limited Guidance CodesCPTCovered

77012	Fluoroscopic guidance for percutaneous procedures (example guidance code)
76942	Ultrasound guidance for vascular access (example)

Modifiers and Reporting RulesModifier

-26	Professional component
-TC	Technical component

Other Relevant CodesCPT

72191

MR pelvis or sacrum (included when relevant to SI joint imaging)

Provider Actions & Billing Rules

Documentation Required

In-person clinical evaluation required

Initial in-person clinical evaluation must be performed prior to requesting advanced imaging for the current episode. The in-person exam must include a relevant history and a detailed neurologic examination (manual muscle testing, dermatomal sensory distribution, reflex testing, and nerve root tension signs). Telehealth/telephone/email does not satisfy the in-person requirement for an initial evaluation. Document recency when indicated by specific sections.

History: recent detailed history since onset/change in symptoms (document date of onset/change).
Neurologic exam: manual motor testing with documented muscle grades, dermatomal sensory distribution, reflex examination, and nerve root tension signs (e.g., straight leg raise, slump test, femoral nerve tension test).
Recency: exam must be for the current episode (performed before advanced imaging request); clinical re-evaluation requirements vary by section (see conservative therapy recency); telehealth/other contacts do not substitute for initial in-person evaluation.

Documentation Required

Document conservative therapy trial

Document that the patient underwent a provider-directed conservative therapy trial and a subsequent clinical re-evaluation prior to advanced imaging unless a Red Flag Indication is present. The required conservative trial is six weeks and the clinical re-evaluation documenting failure of significant clinical improvement must be recent (within the prior 12 weeks). Exceptions apply for Red Flag Indications where immediate advanced imaging is indicated.

Conservative therapy duration: 6-week trial of provider-directed treatment.
Timing/recency: clinical re-evaluation documenting failure of significant improvement should be within 12 weeks of the imaging request.
Exceptions: any Red Flag Indication (e.g., motor weakness, cauda equina, infection, fracture, cancer, severe radicular pain) obviates the conservative trial requirement.

Prior Authorization

Prior authorization may be required for 3D rendering (76376/76377)

Prior authorization may be required for CPT 76376 and 76377 (3D rendering) even when the underlying imaging/procedure does not require prior authorization. When using these codes, document the physician's concurrent supervision/participation as required by the codes. Note: plans may request PA for the 3D codes even if the index procedure does not need PA.

CPT codes: 76376, 76377 require documentation of physician participation.
PA requirement: obtain prior authorization for 76376/76377 when plan rules require it even if the underlying procedure lacks PA.

Documentation Required

Document active physician participation for 3D post-processing

For CPT 76376/76377, document active physician participation (concurrent supervision) in the 3D post-processing. The documentation should describe the physician's role and monitoring during reconstruction and the specific elements determined by the physician.

Design of the anatomic region reconstructed (region selection).
Determination of tissue types/structures to be displayed (e.g., bone, organs, vessels).
Specification of images or cine loops to be archived.
Monitoring and adjustment of the 3D work product during reconstruction.

Billing Rule

Guidance codes: one unit per encounter and pairing rules

Guidance/interventional imaging codes are limited to one unit per encounter and have specific pairing rules. Do not bill a diagnostic CT/MRI in the same session as an imaging guidance code when the guidance code includes the necessary imaging. 77021 is not appropriate for MRI-guided breast biopsy; use biopsy codes instead.

One unit per encounter applies to guidance codes including: 77012, 77013, 77021, 77022, 76942, and fluoroscopy codes (77002-77003).
Do not bill a diagnostic CT (e.g., 70486) or diagnostic CT code with stereotactic guidance code 77011 for the same session; similarly, do not bill diagnostic CT with guidance codes that inherently provide the imaging.
CPT 77021 (MR guidance for needle placement) is not appropriate for breast biopsy—use 19085/19086 for MRI-guided breast biopsy.

Denial Risk

Quantitative MR analysis investigational / NMN

Quantitative multiparametric MR analysis and volumetric/quantitative brain MRI analysis are considered investigational or not medically necessary. Expect potential denials for these Category III and related codes.

Investigational / NMN codes: 0648T, 0649T, 0697T, 0698T, 0865T, 0866T

Prior Authorization

Plain x-rays and imaging recency requirements for prior auth

Plain radiographs and other imaging recency requirements apply for prior authorization in specific scenarios. Ensure required x-rays or imaging studies are performed within the policy-specified windows and include documentation. There are special look-back and timing rules for injections, pre-op imaging, and post-procedure CT.

Plain x-rays: when required by the guideline, plain films must be performed after the current episode started/changed and results must be available to the requesting provider.
Pre-operative imaging: advanced imaging for surgical planning should be performed within 6 months prior to spine surgery.
Injection imaging look-back: MRI/CT for cervical or thoracic interlaminar/transforaminal epidural injections should be within 24 months when indicated; for lumbar transforaminal injections, imaging timing per section (commonly 24 months when criteria met).
Post-vertebral augmentation: CT without contrast of the affected region within 24 hours post-procedure to evaluate for cement extravasation.
Exceptions: for ankylosing spondylitis/DISH, plain x-rays and a 6-week conservative trial/clinical re-evaluation may be waived for trauma and whole-spine imaging can be approved.

Documentation Required

Document rationale for bone scan/SPECT/SPECT-CT

Document the clinical rationale when selecting bone scan/SPECT/SPECT-CT for nuclear medicine evaluation. Typical indications include implant loosening, nondiagnostic MRI/CT for suspected failed fusion, osteomyelitis, spondylolysis, and occult fractures.

Indications: suspected implant loosening when plain x-ray nondiagnostic; failed fusion/pseudoarthrosis with nondiagnostic MRI/CT; initial evaluation or follow-up for osteomyelitis; suspected spondylolysis (especially radiographically occult); radiographically occult vertebral compression fractures.
Relevant CPT codes typically used: 78300/78305/78306/78315 (bone scans), 78803/78831 (SPECT), 78830/78832 (SPECT/CT).

Background & Evidence

Background: These are UnitedHealthcare proprietary, evidence‑based clinical guidelines that evaluate advanced imaging and procedures across modalities (nuclear medicine, ultrasound, CT, MRI, PET, radiation oncology and selected procedural imaging). They are intended to guide appropriate imaging selection, support Choosing Wisely initiatives, and are reviewed annually. This Part 1 contains preface and general guidance and specifically applies to adult spine imaging for Ohio members (Part 1 of 6; effective November 1, 2025; Version V1.0.2025).

Evidence Source	Takeaway
FDA Gadolinium Retention (FDA 2018)	Recommend limiting GBCA use to situations where contrast yields necessary additional information; assess repetitive GBCA use
ACR Practice Parameters / Appropriateness Criteria (MRI/CT/US/PET)	Provide modality-specific performance standards and support MRI/CT after failed conservative care; referenced throughout spine indications
Conservative care outcome (multiple studies/meta-analyses)	Most acute neck/back pain improves after ~6 weeks of provider-directed conservative therapy; imaging before this often not beneficial and linked to higher intervention rates
Risk of early MRI / imaging overuse studies	Early MRI associated with increased rates of surgery (e.g., reported eightfold increase); imaging can lead to downstream interventions without improved outcomes
Nuclear Medicine / SPECT indications (SP-17) and evidence	SPECT/CT and bone scan supported for radiographically occult spondylolysis, implant loosening, failed fusion workup, and occult fractures when MRI/CT nondiagnostic—not for routine initial LBP
3D Rendering CPT 76376/76377 guidance	3D post-processing codes require documented active physician participation; not for 2D reformatting and may need prior authorization
CT/MR/US Guidance Procedure Codes (77012,77021,77013,76942,19085 etc.)	Guidance codes include imaging needed for procedures; bill appropriately (one unit per encounter) and avoid billing diagnostic codes concurrently
Billing restrictions for 3D rendering and guidance codes	Do not report 3D rendering with certain studies (CAD/MRA/CTA/SPECT/PET/etc.) and avoid duplicate billing (e.g., 70486 with 77011)

Definitions

Concurrent supervision (3D rendering): active physician participation and monitoring of the 3D reconstruction process (design of anatomic region, tissue types/structures displayed, images archived, monitoring/adjustment) is required to bill CPT 76376/76377; document supervision or participation.

Standard imaging: plain film, CT, MRI, or ultrasound typically used for initial and subsequent evaluations.

Radiculopathy: for the purpose of this policy, pain in a specified dermatomal distribution causing significant functional limitation plus one or more objective neurologic findings (e.g., motor weakness, sensory change, reflex asymmetry) or concordant imaging/EMG evidence.

Radiculitis: radicular pain without objective neurological findings.

Red Flag Indications (SP‑1.2): clinical features that obviate the requirement for a conservative trial (examples include motor weakness, cauda equina, infection, fracture, cancer, severe radicular pain, aortic aneurysm/dissection).

DISH: diffuse idiopathic skeletal hyperostosis.

Advanced diagnostic imaging studies: imaging such as MRI, CT, CT/myelography, and SPECT/CT as referenced in the Spine Imaging Guidelines.

title": "Upper Back (Thoracic Spine) Pain without and with Neurological Features (Including Stenosis) (SP-4.1)", "type": "criteria_group" }, { "citations": [], "intro": "Lower extremity pain with neurologic features including radiculopathy, radiculitis, plexopathy and neuropathy.", "nodes": [ "{\"operator\":\"any\",\"text\":\"Lower Extremity Pain with Neurological Features (Radiculopathy, Radiculitis, or Plexopathy and Neuropathy) (SP-6.1):\",\"children\":[{\"operator\":\"all\",\"text\":\"Acute or subacute lower extremity radiculopathy with objective neurologic findings (dermatomal sensory loss, myotomal weakness, diminished reflexes) or progressive symptoms: MRI of the lumbar (and when indicated lumbosacral or thoracolumbar) spine is indicated to evaluate for nerve root compression; CT myelography if MRI contraindicated.\",\"children\":[]},{\"operator\":\"all\",\"text\":\"Chronic radicular symptoms without objective neurologic deficit: imaging may be considered after an adequate trial of conservative therapy and when findings would change management; MRI is preferred.\",\"children\":[]},{\"operator\":\"all\",\"text\":\"Suspected plexopathy or peripheral neuropathy: consider targeted imaging (MRI neurography) or EMG/nerve conduction studies as appropriate; spine imaging is indicated when clinical assessment suggests a proximal (root or cord) cause correlating with imaging.\",\"children\":[]}]}" ], "title": "Lower Extremity Pain with Neurological Features (Radiculopathy, Radiculitis, or Plexopathy and Neuropathy) (SP-6.1)", "type": "criteria_group" }, { "citations": [], "intro": "Criteria for imaging in suspected spondylolysis or spondylolisthesis.", "nodes": [ "{\"operator\":\"any\",\"text\":\"Spondylolysis / Spondylolisthesis (SP-8):\",\"children\":[{\"operator\":\"all\",\"text\":\"Initial evaluation: plain radiographs (including oblique views when indicated) are appropriate for suspected spondylolysis or spondylolisthesis.\",\"children\":[]},{\"operator\":\"all\",\"text\":\"CT: CT is indicated when detailed bony anatomy is required, such as to evaluate pars defect, fracture characterization, or preoperative planning for fixation.\",\"children\":[]},{\"operator\":\"all\",\"text\":\"MRI: MRI is useful to assess associated soft tissue, neural element compromise, marrow edema (acute stress reaction), and to evaluate for other causes of back pain; consider MRI when neurologic symptoms or concern for acute pars stress/injury exist.\",\"children\":[]},{\"operator\":\"all\",\"text\":\"SPECT/CT or bone scan: may be considered to detect active pars stress lesions when radiographs and CT are inconclusive and clinical suspicion remains high.\",\"children\":[]}]}" ], "title": "Spondylolysis / Spondylolisthesis (SP-8)", "type": "criteria_group" } ], "id": "medical-necessity-criteria", "label": "MEDICAL-NECESSITY", "title": "Medical-Necessity Criteria (Spine Imaging)" } }>}'

Prior to Interventional Spinal Injections (SP-16.2): Advanced imaging not required prior to facet injections, medial branch blocks or RF ablations unless criteria met. Cervical/thoracic advanced imaging is indicated within 24 months prior to interlaminar or transforaminal epidural steroid injections when criteria met. Lumbar advanced imaging indicated prior to lumbar transforaminal ESI when criteria met; not required for lumbar interlaminar/caudal ESI 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 required for initial epidural injection trial when ALL: diagnostic evaluation ruled out other causes, significant functional limitations, failure of ≥4 weeks conservative treatment.24 months for pre-injection cervical/thoracic; 4 weeks conservative failure for stenosis injection

Red flag considerations may supersede timing.

OpenPayer

Adult Spine Imaging Guidelines

Coverage Summary

Medical-Necessity Criteria (Spine Imaging)

Condition-Specific Indications (Neck, Thoracic, Lumbar, Postoperative, Deformity, Nuclear Medicine)

Coding

Provider Actions & Billing Rules

Background & Evidence

Definitions

Revision History