CurrentUnitedHealthcarePolicy CSNCT0254.05

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

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This policy governs coverage of dynamic spinal visualization techniques and vertebral motion analysis for UnitedHealthcare Community Plan members in North Carolina. Digital motion x-ray, cineradiography/videofluoroscopy, and vertebral motion analysis are considered unproven and not medically necessary because evidence is insufficient.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSNCT0254.05

Change TypeNon-material update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionClaims for digital motion x-ray, cineradiography/videofluoroscopy, or vertebral motion analysis may be denied because these services are unproven and not medically necessary.

SourceLink

POLICY UPDATE CHANGES

The Supporting Information, Clinical Evidence, and References sections were updated to reflect current information.

NCApplicable state

2Dynamic spinal visualization techniques unproven and not medically necessary

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CurrentUnitedHealthcarePolicy CSNCT0254.05

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

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Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSNCT0254.05

Change TypeNon-material update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionClaims for digital motion x-ray, cineradiography/videofluoroscopy, or vertebral motion analysis may be denied because these services are unproven and not medically necessary.

SourceLink

POLICY UPDATE CHANGES

The Supporting Information, Clinical Evidence, and References sections were updated to reflect current information.

NCApplicable state

2Dynamic spinal visualization techniques unproven and not medically necessary

Medical Necessity Criteria

Not medically necessary services

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

Dynamic spinal visualization techniques

Digital motion x-ray of the spine when used to visualize movement of the back or spine.
Cineradiography/videofluoroscopy when used to visualize movement of the back or spine.

Vertebral motion analysis.

Digital motion x-ray of the spine and cineradiography/videofluoroscopy used to visualize movement of the back or spine are excluded from medical necessity because they are considered unproven.

Vertebral motion analysis is excluded from medical necessity because it is considered unproven.

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

Vertebral motion analysis is not medically necessary because there is insufficient evidence of efficacy.

Applicable 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 Impact

Denial Risk

Claims may be denied as unproven services

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

Digital motion x-ray of the spine is unproven and not medically necessary when used to visualize movement of the back or spine.
Cineradiography/videofluoroscopy is unproven and not medically necessary when used to visualize movement of the back or spine.
Vertebral motion analysis is unproven and not medically necessary due to insufficient evidence of efficacy.

Clinical Background

Dynamic spinal visualization technologies are intended to depict movement of the back or spine. The policy addresses digital motion x-ray of the spine and cineradiography/videofluoroscopy, as well as vertebral motion analysis, which evaluates vertebral movement.

Key Terms

Dynamic spinal visualization

ScopeA general term for imaging technologies that simultaneously visualize spine (vertebrae) movements and external body movement.

Digital motion x-ray

Imaging methodUses film or computer-based x-ray snapshots taken in sequence as an individual moves in front of an x-ray camera.

Digital processingFilm x-rays are digitized, while computer-based x-rays are created digitally; the snapshots are arranged sequentially by computer and played on a video monitor as a moving image.

EvaluationThe moving image may be evaluated by a physician or by computer analysis of aspects of body structure to identify abnormalities.

Videoradiography/cineradiography

Excluded Services

The following services are not covered: digital motion x-ray of the spine used to visualize spinal movement; cineradiography/videofluoroscopy used to visualize movement of the back or spine; and vertebral motion analysis. These services are considered unproven and not medically necessary due to insufficient evidence of efficacy.