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    v1.0.30
    OpenPayerPolicy UpdatesRadiology/Diagnostic ImagingUnitedHealthcare Spinal Imaging Update | OpenPayer
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    CurrentUnitedHealthcarePolicy CS254NM.D

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

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    This policy applies to UnitedHealthcare Community Plan members in New Mexico and addresses dynamic spinal visualization techniques and vertebral motion analysis, which are considered unproven and not medically necessary due to insufficient evidence of efficacy.

    Policy Summary
    PayerUnitedHealthcare
    PolicyDiagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis (for New Mexico Only)
    Policy CodePolicy CS254NM.D
    Change TypeAdministrative and supporting-information update
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionTreat claims for digital motion x-ray, cineradiography/videofluoroscopy used to visualize back or spine movement, and vertebral motion analysis as at risk for denial because these services are unproven and not medically necessary.
    SourceLink
    POLICY UPDATE CHANGES

    The Clinical Evidence and References sections were updated with current supporting information.

    New MexicoApplicable state
    2Unproven dynamic spinal visualization techniques

    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.

    1Unproven vertebral motion analysis category
    3Reference procedure codes

    Coverage Criteria

    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 or vertebral motion analysis

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

      Unproven and not medically necessary.

    • Cineradiography or videofluoroscopy is used to visualize movement of the back or spine.

      Unproven and not medically necessary.

    • Vertebral motion analysis is performed.

      Unproven and not medically necessary.

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

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

    Covered Indications

    Visualization of movement of the back or spine or assessment of vertebral motion

    Policy-specified dynamic spinal visualization or vertebral motion analysis: The service is used to visualize movement of the back or spine or to perform vertebral motion analysis.

    The policy classifies the listed services as unproven and not medically necessary regardless of indication.

    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

    Do not bill identified dynamic spinal services as medically necessary

    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 at risk of denial because these services are unproven and not medically necessary due to insufficient evidence of efficacy.

    • Digital motion x-ray of the spine used to visualize movement of the back or spine
    • Cineradiography/videofluoroscopy used to visualize movement of the back or spine
    • Vertebral motion analysis

    Clinical Background

    Dynamic spinal visualization techniques are intended to visualize movement of the back or spine using digital motion x-ray or cineradiography/videofluoroscopy. The policy considers these services, along with vertebral motion analysis, unproven because available evidence is insufficient to establish their efficacy.

    Key Definitions

    Dynamic spinal visualization
    DefinitionA general term for imaging technologies that simultaneously visualize spine (vertebrae) movements and external body movement.
    Digital motion x-ray
    DefinitionUses film or computer-based x-ray snapshots taken in sequence as an individual moves in front of an x-ray camera.
    Image processingFilm x-rays are digitized, while computer-based x-rays are created digitally; the snapshots are ordered by computer 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.

    Not Covered Services

    The following services are not covered: digital motion x-ray of the spine used to visualize movement of the back or 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 New Mexico Only)
    Policy CodePolicy CS254NM.D
    Change TypeAdministrative and supporting-information update
    Effective DateOctober 1, 2026
    Next Review DateNot specified
    Key ActionTreat claims for digital motion x-ray, cineradiography/videofluoroscopy used to visualize back or spine movement, and vertebral motion analysis as at risk for denial because these services are unproven and not medically necessary.
    SourceLink
    On This Page
    Coverage CriteriaCovered IndicationsApplicable CodesProvider and Billing GuidanceClinical BackgroundKey DefinitionsNot Covered Services
    TerminologyVideoradiography and cineradiography are different names for the same procedure.
    Display and analysisImages can be displayed on a video monitor during the procedure and can also be viewed or digitally analyzed.
    Vertebral motion analysis
    DefinitionA system that provides assisted bending with fluoroscopic imaging and computerized analysis to assess vertebral movement.
    Tracking methodFacial recognition software tracks vertebral bodies across the images.
    AssessmentThe system evaluates vertebral movement across the entire series of imaging rather than only at the end range of flexion and extension bending.