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    v1.0.30
    OpenPayerPolicy UpdatesRadiology/Diagnostic ImagingUnitedHealthcare Dynamic Spine Coverage | OpenPaye…
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    CurrentUnitedHealthcarePolicy CS254KS.03

    Diagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for Kansas Only)

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    This UnitedHealthcare Community Plan medical policy governs coverage of dynamic spinal visualization techniques and vertebral motion analysis for Kansas Medicaid members. The services are considered unproven and not medically necessary because evidence is insufficient to establish improved diagnostic accuracy or clinical outcomes.

    Policy Summary
    PayerUnitedHealthcare
    PolicyDiagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for Kansas Only)
    Policy CodePolicy CS254KS.03
    Change TypeAdministrative and evidentiary updateno material coverage change
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionClaims for digital motion x-ray, cineradiography or videofluoroscopy used to visualize spinal movement, or vertebral motion analysis are subject to denial because these services are unproven and not medically necessary.
    SourceLink
    POLICY UPDATE CHANGES

    The policy updates the clinical evidence and reference sections with current supporting information.

    Kansas onlyGeographic applicability
    3

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Procedure codes listed
    3Unproven, not medically necessary categories
    Insufficient evidencePrimary basis for noncoverage

    Coverage Criteria

    Dynamic spinal visualization and vertebral motion analysis

    Not medically necessary when any of the following services is used to evaluate movement of the back or spine.

    Unproven dynamic spinal visualization or vertebral motion analysis

    • Digital motion x-ray of the spine is used to visualize spinal movement.

      Unproven and not medically necessary.

    • Cineradiography/videofluoroscopy: Cineradiography or videofluoroscopy is used to visualize spinal movement.

      Unproven and not medically necessary.

    • Vertebral motion analysis is performed.

      Unproven and not medically necessary.

    Digital motion x-ray of the spine and cineradiography/videofluoroscopy are excluded from coverage when used to visualize movement of the back or spine. These services are considered unproven and not medically necessary because evidence is insufficient to demonstrate efficacy.

    Vertebral motion analysis is excluded from coverage. The service is considered unproven and not medically necessary because evidence is insufficient to demonstrate efficacy.

    Dynamic spinal visualization techniques—including digital motion x-ray of the spine and cineradiography/videofluoroscopy—are unproven and not medically necessary when used to visualize movement of the back or spine. Vertebral motion analysis is likewise unproven and not medically necessary. The coverage position is based on insufficient evidence of efficacy.

    Applicable Codes

    Applicable CPT CodesCPT
    0693TComprehensive full body computer-based markerless 3D kinematic and kinetic motion analysis and report.
    76120Cineradiography/videoradiography, except where specifically included.
    76125Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure)

    Provider and Billing Guidance

    Denial Risk

    Expect denial for unproven spinal motion services

    Claims for digital motion x-ray of the spine, cineradiography or videofluoroscopy used to visualize spinal movement, or vertebral motion analysis are subject to denial because these services are unproven and not medically necessary due to insufficient evidence of efficacy.

    • Do not expect coverage when these services are used to evaluate movement of the back or spine.
    Denial Risk

    FDA status does not establish coverage

    FDA approval or authorization of a product used for diagnostic dynamic spinal visualization or vertebral motion analysis does not by itself establish coverage. FDA approval alone is not a basis for coverage.

    • Review the applicable coverage criteria separately from the product’s FDA status.

    Background

    Dynamic spinal visualization techniques are intended to visualize movement of the back, spine, or vertebrae. They include sequential digital x-ray imaging and real-time fluoroscopic video. Vertebral motion analysis uses assisted bending, fluoroscopic imaging, and computerized analysis to assess vertebral movement.

    Definitions

    Dynamic spinal visualization
    DefinitionA general term for imaging technologies that simultaneously visualize spine (vertebrae) movements and external body movement.
    Digital motion x-ray
    DefinitionSequential film or computer-based x-ray snapshots taken as an individual moves in front of an x-ray camera. The snapshots are ordered and displayed as a moving image for physician or computer evaluation.
    Cineradiography/videoradiography
    DefinitionA fluoroscopy-based procedure that creates realtime video images of internal body structures. Videoradiography and cineradiography are different names for the same procedure.

    Not Covered Services

    The following services are not covered when used to evaluate spinal movement: digital motion x-ray of the spine; cineradiography or videofluoroscopy used to visualize movement of the back or spine; and vertebral motion analysis.

    Policy Summary
    PayerUnitedHealthcare
    PolicyDiagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for Kansas Only)
    Policy CodePolicy CS254KS.03
    Change TypeAdministrative and evidentiary updateno material coverage change
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionClaims for digital motion x-ray, cineradiography or videofluoroscopy used to visualize spinal movement, or vertebral motion analysis are subject to denial because these services are unproven and not medically necessary.
    SourceLink
    On This Page
    Coverage CriteriaApplicable CodesProvider and Billing GuidanceBackgroundDefinitionsNot Covered Services
    Vertebral motion analysis
    DefinitionA system that uses assisted bending with fluoroscopic imaging and computerized analysis to assess vertebral movement, including facial recognition software to track vertebral bodies across images.