CurrentUnitedHealthcarePolicy CS254KY.05

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

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This policy governs coverage of digital motion X-ray, cineradiography/videofluoroscopy, and vertebral motion analysis used to visualize spinal movement. It applies only to UnitedHealthcare Community Plan members in Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicyDiagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for Kentucky Only)

Policy CodePolicy CS254KY.05

Change TypeAdministrative updateno material clinical or coverage changes

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionClaims for digital motion X-ray, cineradiography/videofluoroscopy, or vertebral motion analysis are subject to denial because these services are unproven and not medically necessary.

SourceLink

POLICY UPDATE CHANGES

The policy updates its clinical evidence and references sections and archives the previous policy version.

Kentucky onlyGeographic applicability

3Listed procedure codes

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CurrentUnitedHealthcarePolicy CS254KY.05

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

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Policy Summary

PayerUnitedHealthcare

PolicyDiagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for Kentucky Only)

Policy CodePolicy CS254KY.05

Change TypeAdministrative updateno material clinical or coverage changes

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionClaims for digital motion X-ray, cineradiography/videofluoroscopy, or vertebral motion analysis are subject to denial because these services are unproven and not medically necessary.

SourceLink

POLICY UPDATE CHANGES

The policy updates its clinical evidence and references sections and archives the previous policy version.

Kentucky onlyGeographic applicability

3Listed procedure codes

Medical Necessity and Unproven Services

Not medically necessary and unproven services

The following services are unproven and not medically necessary due to insufficient evidence of efficacy.

Unproven dynamic spinal visualization and vertebral motion analysis

Digital motion X-ray of the spine is unproven and not medically necessary.
Cineradiography/videofluoroscopy used to visualize movement of the back or spine is unproven and not medically necessary.
Vertebral motion analysis is unproven and not medically necessary.

Dynamic spinal visualization techniques used to visualize movement of the back or spine—including digital motion X-ray of the spine and cineradiography/videofluoroscopy—are unproven and not medically necessary because evidence of efficacy is insufficient.

Vertebral motion analysis is excluded as unproven and not medically necessary because evidence of efficacy is insufficient.

Digital motion X-ray of the spine and cineradiography/videofluoroscopy used to visualize movement of the back or spine are not medically necessary because the available evidence is insufficient to establish their efficacy.

Vertebral motion analysis is not medically necessary because the available evidence is insufficient to establish its efficacy.

Applicable Procedure Codes

Applicable CPT CodesCPT

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

Claims and Coverage Implications

Denial Risk

Claims may be denied for unproven dynamic spinal imaging

Claims for digital motion X-ray of the spine, cineradiography/videofluoroscopy used to visualize movement of the back or spine, 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 for digital motion X-ray of the spine.
Do not expect coverage for cineradiography/videofluoroscopy used to visualize movement of the back or spine.
Vertebral motion analysis is also unproven and not medically necessary.

Clinical and Technical Background

Dynamic spinal visualization uses imaging technologies to visualize vertebral movement and external body movement. Digital motion X-ray creates sequential X-ray images during movement, while cineradiography or videoradiography uses fluoroscopy to produce real-time video images. Vertebral motion analysis combines assisted bending, fluoroscopic imaging, and computerized analysis to assess vertebral movement.

Key Terms

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, then arranged and played on a video monitor as a moving image.

Cineradiography/videoradiography

DefinitionA fluoroscopic procedure that creates real-time video images of internal body structures.

Related terminologyVideoradiography and cineradiography are different names for the same procedure.

Services Excluded From Coverage

The following services are not covered because they are considered unproven and not medically necessary: digital motion X-ray of the spine used to visualize spinal movement; cineradiography or videofluoroscopy used to visualize movement of the back or spine; and vertebral motion analysis.