Pediatric and Special Populations Spine Imaging Guidelines (For Ohio Only)
Clinical guideline governing advanced spine imaging for pediatric and special populations in Ohio; applies to UnitedHealthcare Ohio medical necessity determinations for imaging services referenced in the guideline.
Policy Summary
PayerUnitedHealthcare
PolicyPediatric and Special Populations Spine Imaging Guidelines (For Ohio Only)
Policy CodePolicy CSRAD025OH.D
Change TypeClarified (annual/interim updates)
Effective DateNov 1, 2025
Next Review DateN/A
Key ActionObtain and submit recent plain x-ray results and clinical documentation before requesting advanced spinal imaging; prior authorization expected when criteria are met.
Annual and interim evidence-based updates were made in 2024 and 2025.
V1.0.2025guideline version
Nov 1, 2025effective date
107document pages
≤18pediatric age threshold
GFR <30
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.
renal threshold
Coverage Criteria and Clinical Requirements
General requirement for advanced imaging
Covered when ALL of the following are met
Clinical evaluation and documentation: Recent detailed history and physical exam since onset or change in symptoms, and relevant laboratory and prior imaging studies are provided to support the request.
Includes meaningful technological contact (telehealth, telephone, electronic messaging) when applicable.
Appropriate sequencing of studies: Standard or less-invasive imaging (plain radiography, ultrasound, CT, MRI) and review of prior studies have been considered and performed as required by the condition-specific guideline prior to advanced imaging.
Spine/musculoskeletal requests require plain x-rays from the current episode when specified.
Impact on management: The requested advanced imaging is expected to affect individual management or treatment decisions (diagnosis, surgical planning, or change in therapy).
Repeat imaging is supported only when there is evidence of progression, new disease, or when the result will change management.
Modality substitution and contrast considerations
Coverage and substitution rules
CT in lieu of MRI: A CT may be approved in place of an MRI when clinical criteria for MRI are met but MRI is contraindicated (e.g., pacemaker, ICD, insulin pump, neurostimulator).
When replacing MRI with CT, match the contrast level (e.g., MRI without contrast → CT without contrast; MRI without and with contrast → CT with contrast or CT without and with contrast).
Contrast risk parity: Contrast-enhanced CT and contrast-enhanced MRI carry similar renal risk in individuals with renal failure and should be managed similarly.GFR <30 mL/min
Exercise caution with gadolinium in renal impairment and avoid GBCA in pregnancy unless benefit outweighs risk.
3D rendering and guidance clinical scenarios and conditions
3D rendering (CPT 76376/76377) and image-guidance codes (CPT 77011-77013, 77021-77022, 76942, 75989) are appropriate in the following circumstances when imaging will impact management:
Appropriate uses: 3D rendering (CPT 76376/76377) and the listed guidance codes are appropriate for pre-operative planning or management when conventional imaging is insufficient — examples include evaluation of congenital skull abnormalities in newborns/infants/toddlers, complex comminuted or displaced fractures/dislocations (including spine, pelvic/acetabular, intra-articular fractures), complex facial fractures, other complex surgical planning cases, and select cerebrovascular or pelvis/abdominal indications referenced in condition-specific guidelines.
Concurrent physician supervision/participation must be documented for CPT 76376/76377 per ACR recommendations; providers may be required to obtain prior authorization for these 3D codes.
Billing constraints and inappropriate uses
Rules for appropriate coding and billing combinations
Billing rules: Do not bill 3D rendering codes for 2D reformatting; do not report CPT 76376/76377 in conjunction with CAD, MRA, CTA, SPECT, PET, PET/CT, mammography, MRI breast, ultrasound breast, CT colonography, cardiac MRI/CT, or coronary CTA. Do not report CPT 77011 and a diagnostic CT code for the same stereotactic localization session. CPT 77021 is not appropriate for MRI-guided breast biopsy (use CPT 19085/19086). Only one unit of radiologic guidance codes (e.g., 77012, 77021, 76942, 77002-77003, 77013, 77022) should be reported per individual encounter (date of service).
CPT 77013 is for non-bone ablation procedures; CPT 20982 covers CT guidance for bone tumor ablations.
Coverage and conditional criteria
Coverage stances and conditional allowances from the guidelines:
Whole-body CT screening: Whole-body CT/LifeScan for screening asymptomatic individuals is not indicated; exception: whole-body low-dose CT is supported for oncologic staging in Multiple Myeloma.
Whole-body MRI general stance: Whole-body MRI (WBMRI) is generally not supported due to lack of standardization and insufficient evidence of improved outcomes, except for select cancer predisposition syndromes and some autoimmune conditions where interval WBMRI may be recommended.
WBMRI must be reported using CPT 76498 when appropriate.
PET-MRI conditional allowance: PET-MRI may be appropriate when the individual meets condition-specific PET-MRI guidelines OR meets PET-CT criteria and PET-CT is unavailable and the provider requests PET-MRI; when appropriate report as CPT 78813 + CPT 76498.
Quantitative mp-MRI coverage stance:
General Spine Imaging Preconditions
Covered when ALL of the following are met:
Pertinent clinical evaluation: A pertinent clinical evaluation since onset or change in symptoms including detailed history, physical exam with neurologic exam, appropriate labs, and basic imaging has been performed prior to advanced imaging (unless scheduled surveillance).
A meaningful technological contact can serve as the evaluation.
Symptomatic disease only: Advanced spine imaging is only supported for individuals with documented active clinical signs or symptoms of spine disease; screening asymptomatic individuals is not supported.
Plain x-ray when required: When condition-specific guidelines require plain radiography prior to advanced imaging, the x-ray must have been performed after the current episode started or changed and results must be available to the requesting provider.
Repeat imaging:
Age-based imaging guideline assignment
Pediatric guideline applicability: Patients age ≤18 years should be imaged according to the Pediatric Spine Imaging Guidelines; individuals >18 years follow the General Spine Imaging Guidelines.≤18 years
Modality selection and special considerations
MRI preference: MRI is the preferred modality for pediatric spine imaging unless a specific guideline section recommends another modality; plan MRI sessions to minimize anesthesia exposure and consider obtaining both non-contrast and contrast sequences during the same anesthesia session when IV access is present and contrast may be needed.
Limit GBCA use to situations where contrast adds necessary information and assess repetitive GBCA necessity.
CT indications: CT is generally inferior to MRI for the pediatric spine but is the study of choice in trauma and specific indications (e.g., hardware limiting MRI, severe congenital scoliosis with inconclusive MRI, nerve root avulsion, paraspinal cyst continuity) and may be used when MRI is contraindicated.
CT should not replace MRI solely to avoid sedation unless specifically recommended.
Ultrasound indications: Spinal canal ultrasound (CPT 76800) is generally limited to infants up to 6 months because of the acoustic window; exception for persistent acoustic window in posterior spinal defects permits ultrasound at any age. Do not use 76800 for intraoperative imaging (use 76998).≤6 months (general)
Back and Neck Pain in Children Age 5 and Under
Children age 5 and under
Children ≤5 imaging: Advanced imaging is appropriate for most individuals in this age group except those with mild, transient back pain; MRI of the symptomatic spinal region should be approved.
Recognize need for sedation for MRI in young children; CT without contrast is limited to rare situations when x-ray suggests isolated vertebral bony abnormality or MRI lacks bony detail required for acute care decision-making.
Back and Neck Pain in Children Age 6 and Older
Children age 6 and older
Prerequisite evaluation: Pertinent clinical evaluation and plain x-rays must be performed and x-ray results available to the requesting provider prior to advanced imaging approval.
Indications for advanced imaging without conservative trial: One or more pediatric 'red flags' present: systemic symptoms, functional disability, severe/nocturnal pain, constant or radicular pain ≥4 weeks, pain worsening despite treatment, neurologic symptoms or abnormal exam, cancer (excluding leukemia), abnormal x-rays, prior spinal surgery, or bowel/bladder dysfunction — MRI without contrast preferred and MRI with and without contrast when fever, suspected infection, mass on exam/x-ray, or known cancer with new/worsening pain.4 weeks (for duration of pain)
Conservative therapy requirement: In absence of red flags, require a recent (within 3 months) 4-week trial of provider-supervised conservative treatment before advanced imaging is approved; referral to pediatric spine surgeon may be considered as failing conservative care.4 weeks
Spondylolysis Imaging Criteria
Spondylolysis
Initial evaluation: Pertinent clinical evaluation and plain radiography should be performed prior to advanced imaging; spondylolysis is screened with plain x-rays.
Imaging for persistent symptoms or preop planning: If symptoms persist after a recent (within 3 months) 4-week provider-directed conservative care or preoperative planning is required, MRI without contrast of the symptomatic level is indicated. If radiographically occult or additional bony detail needed, SPECT (CPT 78803) or SPECT/CT (CPT 78830) is indicated; CT without contrast may be used for detailed bony anatomy for preoperative planning.4 weeks
Bone scan/SPECT may be more sensitive for active spondylolysis.
Infectious Spine Pain Imaging
Spine pain due to infectious causes
Initial evaluation: Detailed history and physical with thorough neurologic exam and plain x-rays initially; MRI without and with contrast of the symptomatic level is indicated when discitis or osteomyelitis is suspected. Nuclear medicine studies may be positive within 1-2 days and are indicated as listed.
Initial nuclear options include bone scan (CPT 78300/78305/78306/78315), nuclear bone marrow imaging (78102/78103/78104), radiopharmaceutical inflammatory imaging (78800/78801/78802/78803/78804), SPECT (78831) or SPECT/CT (78830/78832).
Follow-up imaging: Follow-up plain x-rays, MRI without and with contrast, or CT with contrast (including myelography) may be useful; nuclear medicine studies can be used to evaluate treatment response.
Trauma-related Spine Imaging
Trauma and painless spine trauma
General trauma imaging: Clinical examination directs imaging selection; MRI without contrast or CT without contrast of the involved level is indicated when advanced imaging appropriate; if initial CT or MRI is inconclusive, the other modality may be approved.
Cervical spine - children <3: Children under 3 should be approved for advanced cervical spine imaging following a relevant recent x-ray when one or more red flags are present (e.g., GCS <14, no eye opening, motor vehicle collision).
See source for full red-flag list.
Cervical spine - children ≥3: Children ≥3 should be approved for advanced cervical imaging following a recent (within 60 days) x-ray when one or more red flags are present (e.g., altered mental status, focal neurologic findings, neck pain, new torticollis, substantial torso injury, diving/head-first injury, high-speed MVC, predisposing conditions such as Down syndrome).60 days
Cervical spine — Advanced imaging following x-ray
Covered when the following age-specific conditions are met and recent x-ray results are available to the requesting provider.
Children under 3 years: Approve advanced cervical imaging after a relevant recent x-ray when ONE OR MORE red flags present (e.g., GCS <14, no eye opening, motor vehicle collision).
See chunk 108 for full list of red flags.
Children ≥3 years: Approve advanced cervical imaging after a recent (within 60 days) x-ray when ONE OR MORE red flags are present (e.g., altered mental status, focal neurologic findings, neck pain, new torticollis, substantial torso injury, diving/head-first injury, high-speed MVC, predisposing conditions such as Down syndrome).
Children older than 2 years — do not image: Do NOT approve advanced cervical imaging when ALL of: absence of posterior midline cervical pain; absence of focal neurologic deficit; normal level of alertness; no evidence of intoxication; absence of other clinically apparent distracting pain.
Applies to children older than 2 years.
Thoracolumbar spine — Advanced imaging following x-ray
Covered when x-rays are inconclusive or when there is an abnormal neurological examination.
Thoracolumbar advanced imaging: Approve advanced thoracolumbar imaging after a recent x-ray when plain radiographs are inconclusive OR when there is an abnormal neurologic examination.
Suspected physical child abuse — Spine MRI
Covered when documented findings suggest abuse (e.g., fractures on skeletal survey or other clinical indicators).
Abuse-associated MRI: MRI cervical (72141), thoracic (72146), and lumbar (72148) without contrast are indicated to search for associated abnormalities when child abuse is suspected and documented findings suggest abuse.
If IV access for anesthesia is present and no contraindication, MRI without and with contrast may be approved.
Use of contrast with existing IV access: If intravenous access will already be present for anesthesia and there is no contraindication, imaging without and with contrast can be approved.
See pediatric modality considerations (PEDSP-1.3).
Covered when clinical and radiographic evaluation performed first; MRI has limited diagnostic value except preoperatively or to rule out cord problems.
Pre-MRI evaluation: Require detailed history, neurologic exam, and plain radiography (x-rays showing anterior wedging in ≥3 adjacent vertebrae) before considering MRI for juvenile thoracic kyphosis (Scheuermann disease).
Preoperative MRI for cord evaluation: MRI thoracic (72146) without contrast preoperatively to rule out associated spinal cord problems; MRI lumbar (72148) without contrast preoperatively if lumbar abnormalities present.
Covered when specific clinical, radiographic, or surgical planning indications are present.
Initial evaluation: Obtain detailed history, neurologic exam, and standing PA/lateral plain radiographs prior to advanced imaging for scoliosis; use breast shields if AP x-rays performed.
Congenital scoliosis: In infants <6 months, spinal ultrasound (76800) can be approved after initial x-rays; MRI cervical/thoracic/lumbar without contrast is indicated to search for underlying anomalies.
Idiopathic scoliosis with red flags: MRI cervical/thoracic/lumbar without contrast is preferred and should be approved when associated clinical features are present (e.g., age <10, neurologic abnormalities, left-sided curve, rapid progression, midline cutaneous markers).
Neuromuscular scoliosis: MRI without contrast (or with contrast if indicated) or CT without contrast can be approved for painful neuromuscular scoliosis or preoperative evaluation; bone scans may be useful for painful cases.
Occult spinal dysraphism and tethered cord — Imaging
Covered when cutaneous or non-cutaneous indications are present; modality depends on age and findings.
Initial infant imaging: Spinal ultrasound (76800) for infants up to 6 months (corrected age for premature infants) is the initial evaluation; repeat ultrasound in 4–6 weeks if conus position uncertain.4-6 weeks for repeat in premature infants when uncertain
MRI for suspected dysraphism: MRI without contrast (or without and with contrast) of the appropriate spinal level may be approved when plain x-ray suggests abnormality (e.g., absent/distorted pedicle) or when cutaneous/non-cutaneous indications warrant further evaluation; MRI is preferred in older infants and children.
Plain x-rays not indicated: Plain x-rays are not indicated for suspected occult spinal dysraphism/tethered cord in isolation; incidental spina bifida occulta in asymptomatic individuals is not an indication for further imaging.
Indications for imaging
Covered when ANY of the following indication groups apply and the specified modality/age rules are followed:
Cutaneous markers: Cutaneous findings overlying the lower spine (e.g., spinal dimples, deviated/bifid gluteal cleft, dermal sinuses, subcutaneous midline masses, caudal appendages, abnormal hair patches, infantile hemangiomas, complex midline birthmarks above the upper sacral region) — spinal ultrasound (≤6 months) or MRI (>6 months or if ultrasound abnormal) may be approved.
>80% of individuals with occult dysraphism have a cutaneous lesion.
Neurologic/orthopedic/urologic findings: Neurologic signs suggestive of tethered cord (asymmetric/smaller foot, cavus foot, toe walking with UMN signs, ataxia, absent perineal sensation), lower urinary tract dysfunction, constipation with spine findings, or back/leg pain when tethered cord suspected — MRI of involved level without or without and with contrast may be approved regardless of prior x-ray or conservative therapy in some cases.
Follow-up imaging
Covered when specific follow-up criteria are met:
Premature infant follow-up ultrasound: If cord termination is uncertain in a premature infant, repeat spinal ultrasound can be performed in 4 to 6 weeks to assess cranial migration of the conus.4-6 weeks
Postoperative MRI is not routine but may be approved for recurrent symptoms or signs suggestive of recurrent tethering; contrast level determined by the ordering specialist.
Achondroplasia imaging
Covered when ALL of the following are met
achondroplasia_imaging: Clinical diagnosis of achondroplasia with pertinent clinical evaluation (history, neurologic exam) and plain radiography performed prior to advanced imaging; MRI without contrast of the symptomatic spinal region can be approved when new or worsening clinical symptoms suggest achondroplasia-related spinal stenosis.
MRI brain or CT head may be approved when symptoms suggest hydrocephalus.
Atlantoaxial instability in Trisomy 21
Covered when ANY of the following are met
trisomy21_cervical_imaging: Lateral cervical x-ray demonstrates atlantodental interval ≥4.5 mm and/or neural canal width ≤14 mm; OR new or worsening clinical symptoms suggest myelopathy — cervical MRI (72141 or 72156) without or without and with contrast is indicated.atlantodental interval >=4.5 mm; neural canal width <=14 mm
Klippel-Feil anomaly
Covered when ALL of the following are met
klippel_feil_imaging: Initial detailed history, neurologic exam, and plain cervical spine x-rays performed; advanced imaging is indicated if acute or worsening neurologic symptoms (including pain) occur or if multiple levels are involved.
MRI cervical without contrast or CT cervical without contrast are appropriate for these indications.
Marfan syndrome
Covered when ANY of the following are met
marfan_imaging: New or worsening clinical symptoms suggesting complicated dural ectasia; OR the individual is under active consideration for surgery — MRI without contrast of the symptomatic spinal region can be approved.
Inflammatory spondylitis in pediatric patients
Covered when ANY of the following are met
pediatric_jia_imaging: For juvenile idiopathic arthritis, MRI (without and with contrast or without contrast) of the involved levels is appropriate; an initial x-ray is not necessary prior to MRI in these patients.
Whole-body radiopharmaceutical localization imaging or SPECT/SPECT-CT may be appropriate for facet arthropathy evaluation in some conditions.
Von Hippel-Lindau syndrome — spinal hemangioblastoma imaging
Covered when ANY of the following are met
vhl_hemangioblastoma_imaging: MRI without and with contrast of the affected spinal level can be approved for: annual surveillance of asymptomatic unresected spinal hemangioblastoma(s); preoperative planning for resection; or new/worsening symptoms suggesting progression.annual for asymptomatic unresected lesions
Pediatric myelopathy
Covered when ALL of the following are met
pediatric_myelopathy: Imaging indications in pediatric individuals mirror adult myelopathy criteria; follow general myelopathy imaging guidance and condition-specific criteria. Appropriate imaging (MRI/CT) should be ordered based on the clinical presentation and neurologic findings.
Refer to Spine Imaging Guidelines for specific criteria and levels.
Imaging studies that are inconsistent with established clinical standards, or are requested solely for data collection and not used in direct clinical management, are not supported. Such requests will be evaluated against the guideline evidence base and may be excluded from coverage when they do not meet accepted clinical standards or when the results will not affect patient management.
Magnetic resonance techniques using inhaled Xenon Xe 129 (CPT C9791) are considered investigational/experimental and are excluded from guideline-supported MRI contrast or advanced MRI use. These studies lack sufficient evidence of clinical utility and are not supported for routine coverage.
3D rendering codes (CPT 76376, 76377) are restricted from routine pairing with certain modalities and procedures. Do not bill 3D rendering codes when the service is limited to 2D reformatting, and do not report CPT 76376/76377 in conjunction with CAD, MRA, CTA, SPECT, PET, PET/CT, mammography, breast MRI/US, CT colonography, cardiac MRI/CT, coronary CTA, or stereotactic localization codes (e.g., do not report 77011 and a diagnostic CT code for the same session). Concurrent physician supervision and documentation are required when 3D rendering is performed.
Whole-body CT or LifeScan for screening of asymptomatic individuals is not indicated and therefore not supported. The guidelines permit whole-body low-dose CT only for specific oncologic staging (e.g., Multiple Myeloma); routine asymptomatic screening with whole-body CT is disallowed.
Quantitative multiparametric MRI analyses, including Category III quantitative mp-MRI codes, are considered investigational/experimental and are not supported for routine clinical practice due to insufficient evidence of diagnostic utility.
Do not use spinal canal ultrasound CPT 76800 for intraoperative imaging. For intraoperative ultrasonic guidance, report CPT 76998 instead; 76800 is intended for diagnostic spinal canal evaluation (typically in infants).
CT should not be used to replace MRI solely to avoid sedation. A CT may be approved in lieu of MRI only when MRI is contraindicated or a guideline section specifically recommends CT for that indication; modality substitution should follow the contrast-matching rules when applicable.
Plain spine radiographs are not indicated for evaluation of suspected occult spinal dysraphism or tethered cord. Incidental findings such as spina bifida occulta on x-ray in asymptomatic individuals are not an indication for further imaging. Similarly, pilonidal cysts below the intergluteal fold or nonspecific sacral skin findings without other midline abnormalities do not justify spine x-rays.
Plain spine x-rays are not indicated for suspected occult spinal dysraphism or tethered cord and should not be used as a routine screening tool. Note that pilonidal cysts below the intergluteal fold and isolated nonspecific dermal melanosis are not indications for spine imaging.
For Chiari malformations and skull base abnormalities, refer to the separate Pediatric Head Imaging Guidelines (PEDHD-9). Imaging guidance and coverage for Chiari are addressed in that pediatric head guideline rather than within the spine sections.
When applying these coverage rules, providers must reference applicable federal, state (Ohio Administrative Code), or contractual benefit plan requirements, as those higher-priority rules may differ and govern in the event of a conflict.
Studies deemed investigational or experimental because of limited or immature evidence, lack of demonstrated clinical utility, or absence of a collective professional opinion are considered not supported for coverage. Such determinations follow the definitions and evidence thresholds described in the guidelines.
Repeat imaging without evidence of disease progression, recurrence, or a clear expectation that the results will change clinical management is generally unnecessary and may not be approved. Providers should document why repeat imaging is expected to affect patient care.
Pre-operative or pre-procedural imaging is not indicated when the underlying surgery or procedure itself is not indicated. Pre-procedural imaging may be approved only when the planned surgery/procedure has been indicated or approved.
Volumetric and quantitative MRI analysis of the brain (e.g., CPT 0865T and 0866T) lack sufficient specificity and sensitivity for routine clinical use and are considered not medically necessary in routine practice.
Advanced imaging to screen asymptomatic individuals for spine disorders is not supported. Coverage is limited to patients with documented active clinical signs or symptoms where imaging results are expected to influence management.
Children older than 2 years should not be approved for advanced cervical spine imaging when they meet all low-risk criteria (absence of posterior midline cervical pain, absence of focal neurologic deficit, normal level of alertness, no evidence of intoxication, and absence of other clinically apparent distracting pain).
Do not approve advanced cervical imaging for children older than 2 years when ALL of the following low-risk items are present: no posterior midline cervical pain, no focal neurologic deficit, normal alertness, no evidence of intoxication, and no distracting clinically apparent pain.
Routine repeat ultrasound or MRI follow-up after a normal screening spinal ultrasound or a normal screening MRI is not appropriate. A normal screening study generally does not require further routine surveillance imaging unless new clinical concerns arise.
Supported Modalities and Indications
Supported modalities and clinical contexts for each imaging type
Supported modalities and clinical contexts for each imaging type
Ultrasound indications: Ultrasound is appropriate for soft tissue and visceral imaging (chest, abdomen, pelvis, extremities), brain and spine when not obscured by bone, vascular imaging when feasible, procedural guidance, and initial evaluation of ill-defined soft tissue masses; it is operator-dependent and can guide selection of advanced modalities.
See condition-specific guidance for exceptions.
CT indications: CT is indicated for trauma screening, pulmonary disease, abdominal/pelvic viscera, complex fractures, characterization of masses, arterial/venous anatomy, and when MRI is contraindicated or inconclusive; CT contrast decisions are indication-specific.
CT should not replace MRI solely to avoid sedation unless specifically recommended.
MRI indications: MRI is indicated for imaging brain and spinal cord, characterizing soft tissue masses, evaluating ligaments/tendons, and when ultrasound/CT are inconclusive; MRI is preferred in pediatric spine unless otherwise specified.
3D rendering not requiring image post-processing on an independent workstation
76377
3D rendering requiring image post-processing on an independent workstation
Imaging Guidance and Biopsy CodesCPT
19085
Biopsy, breast, with placement of breast localization device(s), percutaneous; first lesion, including MR guidance
19086
Biopsy, breast, with placement of breast localization device(s), percutaneous; each additional lesion, including MR guidance
75989
Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
76942
Ultrasonic guidance for needle placement
77011
CT guidance for stereotactic localization
77012
CT guidance for needle placement
77013
CT guidance for, and monitoring of parenchymal tissue ablation
77021
MR guidance for needle placement
77022
MR guidance for, and monitoring of parenchymal tissue ablation
Bone ablation guidance referenceCPT
20982
CT guidance for bone tumor ablations (reference: CPT 20982 includes CT guidance for bone tumor ablations)
Specific CPT guidance (breast biopsy)CPT
77021
MR guidance for needle placement — not appropriate for breast biopsy (per guidance)
19085
First breast biopsy site (appropriate per guidance)
19086
Additional concurrent breast biopsies (appropriate per guidance)
Guidance codes for ablation and proceduresCPT
77013
CT guidance for tumor ablation — includes guidance, monitoring, repositioning, multiple ablations, and confirmation; use only for non-bone ablation procedures
77022
MR guidance for tumor ablation — includes guidance, monitoring, repositioning, multiple ablations, and confirmation
20982
CT guidance for bone tumor ablations
77012
Radiologic guidance (other modality) — referenced as distinct guidance code
Radiopharmaceutical localization, planar, single area
78801
Radiopharmaceutical localization, planar, 2 or more areas
78802
Radiopharmaceutical localization, planar, whole body
1–10 of 15
1/2
Ultrasound Codes and NotesCPTCovered
76800
Ultrasound, spinal canal and contents
76998
Intraoperative ultrasonic guidance (do not use 76800 for intraoperative use)
PET Codes (notes on pediatric use)CPT
78811
PET Imaging; limited area (not used in pediatrics)
78812
PET Imaging: skull base to mid-thigh (not used in pediatrics)
78813
PET Imaging: whole body (not used in pediatrics)
78814
PET with concurrently acquired CT; limited area (rarely used in pediatrics)
78815
PET with concurrently acquired CT; skull base to mid-thigh
78816
PET with concurrently acquired CT; whole body
UltrasoundCPTCovered
76800
Spinal canal ultrasound
Nuclear Medicine / Bone Scan / SPECTCPTCovered
78300
Bone scan
78305
Bone scan
78306
Bone scan
78315
Bone scan, whole body
78803
Distribution of radiopharmaceutical agent SPECT
78830
SPECT/CT
78831
SPECT
78832
SPECT/CT additional code
CT / Myelogram coding notemixed
CT (unspecified codes)
CT of appropriate spinal level with or without contrast; myelogram coding depends on who performs myelogram
Nuclear bone marrow and inflammatory imagingCPTCovered
78102
Nuclear bone marrow imaging
78103
Nuclear bone marrow imaging
78104
Nuclear bone marrow imaging
78800
Radiopharmaceutical inflammatory imaging
78801
Radiopharmaceutical inflammatory imaging
78802
Radiopharmaceutical inflammatory imaging
78804
Radiopharmaceutical inflammatory imaging
Referenced advanced imaging CPT codesCPT
72141
MRI Cervical Spine without contrast
72146
MRI Thoracic Spine without contrast
72148
MRI Lumbar Spine without contrast
76800
Spinal ultrasound
71260
CT Chest with contrast
71250
CT Chest without contrast
78300
Bone scan - multiple areas
78305
Bone scan - three-phase
78306
Bone scan - limited
78315
Bone scan - single area
Covered CPT Codes (Ultrasound)CPTCovered
76800
Spinal ultrasound
Covered CPT Codes (MRI Spine and Pelvis)CPTCovered
72141
MRI cervical spine without contrast
72146
MRI thoracic spine without contrast
72148
MRI lumbar spine without contrast
72156
MRI cervical spine without and with contrast
72157
MRI thoracic spine without and with contrast
72158
MRI lumbar spine without and with contrast
72195
MRI pelvis without contrast
72196
MRI pelvis without and with contrast
72197
MRI pelvis without and with contrast (alternate listing in doc)
Covered CPT Codes (Brain imaging)CPTCovered
70551
MRI brain without contrast
70553
MRI brain without and with contrast
70450
CT brain without contrast
Brain imaging codes referenced for achondroplasiaCPT
70551
MRI Brain without contrast
70450
CT Head without contrast
Cervical spine imaging codes referencedCPT
72141
MRI Cervical Spine without contrast
72156
MRI Cervical Spine without and with contrast
72125
CT Cervical Spine without contrast
Nuclear medicine codes for facet arthropathy evaluationCPT
78802
Whole body radiopharmaceutical localization imaging
78803
SPECT
78830
SPECT/CT
Renal function threshold (contrast parity)key
GFR <30 mL/min
Both contrast CT and MRI may be considered to have the same risk profile with renal failure (GFR <30 mL/min).
Guidance code units per encounter
Guidance code unit ruleOne unit of radiologic guidance code (e.g., CPT 77013, 77022, 77012, 77021, 76942, 77002-77003) is reported per individual encounter (date of service), not per lesion or procedure step.
Provider Requirements, Prior Authorization, and Documentation
Prior Authorization
Prior authorization expectation
These evidence-based guidelines evaluate advanced imaging and UnitedHealthcare reserves the right to change or update them. Clinicians are expected to use independent medical judgment; the guidelines are intended to facilitate but not supplant clinical decision-making. Prior authorization expectations: UnitedHealthcare may require prior authorization for imaging and related services per plan; when used, InterQual is the primary source for medical/surgical criteria.
UnitedHealthcare may modify guidelines annually.
Prior authorization may be required per member plan benefits.
Prior Authorization
Pre-procedural imaging requirement
Pre-operative, pre-surgical, or pre-procedural advanced imaging will be approved only when the underlying surgery or procedure is indicated. If the procedure has been approved or does not require prior authorization, appropriate pre-procedural imaging may be approved. Ordering providers should ensure the procedure itself meets coverage and medical necessity criteria before requesting pre-procedural imaging.
Frequency and Unit Limits
MRI — Gadolinium use and repetitive GBCA assessment
GBCA repetition assessmentAssess necessity of repetitive gadolinium‑based contrast agent (GBCA) MRIs; limit GBCA use to circumstances where contrast adds necessary diagnostic information.
Contrast when under anesthesiaIf IV access will be present for anesthesia and no contraindication exists, consider obtaining non‑contrast and contrast sequences in the same session to avoid repeat anesthesia exposures.
Gadolinium retention noteAlthough gadolinium deposition has been observed, FDA currently notes no proven harm; nonetheless, repetitive GBCA use should be justified clinically.
CT/MR/US/Fluoroscopy guidance codes — unit reporting
Single guidance unit per encounterOnly one unit of guidance code should be reported per individual encounter (date of service) for CT/MR/US/fluoroscopy guidance procedures.
Authorization Rules and Exceptions
Note
Note
Note
Note
Note
Note
Note
Note
Contrast Use, Renal and Anesthesia Considerations
Note
Note
Note
Note
Note
Note
Note
Note
Not Covered and Exclusions
Unbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported because PET/CT is performed and interpreted as a combined study; separate billing for PET and diagnostic CT to recreate a PET/CT is inappropriate.
Reporting 3D rendering codes for services that are limited to 2D reformatting is not appropriate. Similarly, CPT 77021 is not the correct code for MRI-guided breast biopsy; use CPT 19085 for the first lesion and CPT 19086 for each additional concurrent lesion when applicable.
3D rendering codes should not be billed when the work product is limited to 2D reformatting. For MRI-guided breast biopsy, CPT 77021 is not appropriate; use CPT 19085 and CPT 19086 per lesion as specified.
Do not report 3D rendering codes for cases that involve only 2D reformatting. For MRI-guided breast biopsy procedures, CPT 77021 is not the correct code—use the breast biopsy codes (19085/19086) instead.
Billing 3D rendering codes to represent simple 2D reformatting is not supported. CPT 77021 should not be used for breast biopsy coding; CPT 19085 and 19086 are the appropriate MRI-guided breast biopsy codes.
3D rendering must represent true volumetric post-processing; charging 3D rendering for 2D reformatting is not allowed. Use CPT 19085/19086 for MRI-guided breast biopsy rather than CPT 77021.
Background and Scope
These evidence-based guidelines evaluate advanced imaging modalities (nuclear medicine, ultrasound, CT, MRI, PET), radiation oncology, sleep studies, and interventional procedures for multiple body systems. They are based on peer-reviewed literature, society recommendations, and expert input and are intended to guide appropriate imaging selection while allowing clinician judgment; investigational or experimental procedures lacking sufficient evidence are excluded from coverage.
Investigational/Experimental definitionInvestigational or experimental studies are those with insufficient supporting evidence, immature outcomes, lack of demonstrated clinical utility, or lacking a collective opinion of support.
Evidence standardsSupporting evidence includes peer‑reviewed literature (e.g., RCTs, adequately powered cohort studies) and specialty society recommendations where available.
Coverage implicationProcedures deemed investigational/experimental are not supported under these guidelines for coverage purposes.
Standard or conventional imaging
Standard imaging definedStandard or conventional imaging includes plain film (x‑ray), CT, MRI, and ultrasound (US).
Role in care pathway
Policy Revision History
2025-05-01evidence_updateLatest
Annual evidence-based update recorded for the policy.
2024-07-01evidence_update
Interim evidence-based update recorded for the policy.
2024-02-01evidence_update
Annual evidence-based update recorded for the policy.
Policy Summary
PayerUnitedHealthcare
PolicyPediatric and Special Populations Spine Imaging Guidelines (For Ohio Only)
Policy CodePolicy CSRAD025OH.D
Change TypeClarified (annual/interim updates)
Effective DateNov 1, 2025
Next Review DateN/A
Key ActionObtain and submit recent plain x-ray results and clinical documentation before requesting advanced spinal imaging; prior authorization expected when criteria are met.
Category III quantitative multiparametric MRI analyses (e.g., CPT 0648T, 0649T, 0697T, 0698T) are considered investigational/experimental; volumetric/quantitative brain MRI (CPT 0865T/0866T) is not medically necessary for routine clinical practice.
Repeat advanced imaging is supported only when there is evidence of progression, new disease, or documentation that the repeat study will affect management or treatment decisions.
Spinal ultrasound should not be reported multiple times for different spinal canal areas.
Nuclear medicine use: Nuclear medicine studies are infrequently used but indicated for evaluation of suspected loosening of orthopedic hardware when x-ray is nondiagnostic, and for certain cases such as suspected spondylolysis or when MRI is nondiagnostic (bone scan, SPECT, SPECT/CT).
Examples include CPT 78315, 78803, 78830, 78831, 78832.
Cervical clearance rule: Children older than 2 should NOT be approved for advanced cervical imaging if ALL of the following are present: absence of posterior midline cervical pain, absence of focal neurologic deficit, normal alertness, no evidence of intoxication, and absence of other clinically apparent distracting pain.
Negative rule for imaging approval.
Thoracolumbar imaging: Children should be approved for thoracolumbar advanced imaging following a recent x-ray when x-rays are inconclusive or when there is an abnormal neurological examination.
Bone scan CPTs: 78300/78305/78306/78315.
Postoperative/Perioperative CT chest: Postoperative CT chest (71250/71260) may be indicated for perioperative lung assessment and long-term lung growth monitoring (2 and 5 years) in severe/early-onset scoliosis.
MRI may be approved without prior x-ray or conservative therapy when tethered cord suspected.
Preoperative planning or complex anatomy: MRI of the entire spine and/or CT of the affected spinal level may be approved for preoperative planning or when complex bony deformity is present or MRI is contraindicated.
CT allowed for surgical planning.
Consider anesthesia planning and GBCA use per contrast rules.
PET indications: PET is indicated primarily for oncologic metabolic imaging and usually combined with CT; PET (and PET/MRI) are not supported for routine surveillance unless specified in condition-specific guidelines.
PET-MRI generally not supported except in select circumstances reported as CPT 78813 + 76498.
3D rendering when conventional imaging insufficient and will affect pre-operative planning or management
3D rendering when conventional imaging is insufficient: CPT 76376/76377 3D rendering may be approved when conventional imaging is insufficient and the 3D rendering will affect pre-operative planning or clinical management (e.g., complex bony anatomy, complex fractures, congenital skull abnormalities, select pelvis/abdomen indications).
Documented physician supervision/participation in reconstruction should be present.
MRI-guided breast biopsy coding
MRI-guided breast biopsy coding: For MRI-guided breast biopsy, report CPT 19085 for the first lesion and CPT 19086 for each additional concurrent lesion; CPT 77021 is not appropriate for breast biopsy.
Supported indications for whole-body imaging
Whole-body CT indications: Whole-body low-dose CT is supported for oncologic staging in Multiple Myeloma; routine whole-body CT screening of asymptomatic individuals is not indicated.
WBMRI indications: Interval whole-body MRI may be appropriate for select cancer predisposition syndromes or certain autoimmune conditions (e.g., chronic recurrent multifocal osteomyelitis) as specified in condition-specific guidelines; otherwise WBMRI is generally not supported.
WBMRI reporting must use CPT 76498 when appropriate.
Preferred imaging modality for pediatric spine
MRI preferred for pediatric spine
MRI preferred modality: MRI is the preferred modality for pediatric spine imaging unless a specific guideline section recommends another modality; plan imaging to minimize anesthesia and consider obtaining contrast and non-contrast sequences in the same session when IV access is present and no contraindication.
Contrast use should be limited to when it adds necessary diagnostic information.
CT indications
CT indications summary: CT is the study of choice in trauma and in specific situations where MRI is limited (e.g., hardware, severe congenital scoliosis with inconclusive MRI, nerve root avulsion, paraspinal cyst continuity) and may be used when MRI is contraindicated.
Avoid substituting CT for MRI solely to avoid sedation unless guideline-supported.
Ultrasound indications
Ultrasound indications summary: Spinal canal ultrasound (CPT 76800) is primarily indicated in infants up to 6 months (corrected age for premature infants) and as initial evaluation for suspected dysraphism in this age group; exception exists for posterior spinal defects where ultrasound may be used at any age.≤6 months
Do not use 76800 intraoperatively; use 76998 instead.
Back and neck pain
Back and neck pain guidelines summary: In children ≤5 years MRI of the symptomatic spinal region is appropriate except for mild/transient pain; in children ≥6 years obtain plain x-rays and consider advanced imaging when red flags are present or after a 4-week provider-supervised conservative treatment trial absent red flags.4 weeks for conservative trial (age ≥6)
MRI without contrast preferred; MRI with and without contrast when infection, mass, or cancer concern present.
Spinal canal ultrasound
Spinal canal ultrasound constraint: Spinal canal ultrasound (CPT 76800) is limited to infants up to 6 months due to acoustic window limitations; exception for posterior spinal defects permits use at older ages.6 months
Follow-up of a normal screening spinal ultrasound with repeat ultrasound or MRI is not appropriate unless clinically indicated.
Suspected spondylolysis
Suspected spondylolysis triggers: If symptoms persist after a recent (within 3 months) 4-week provider-directed conservative care or preoperative planning is needed, MRI without contrast is indicated; SPECT or SPECT/CT when radiographically occult; CT without contrast for detailed bony anatomy for preoperative planning.4 weeks
Bone scan/SPECT are sensitive for active spondylolysis.
Advanced cervical spine imaging following recent x-ray
Advanced cervical spine imaging following x-ray: Children under 3: approve advanced cervical imaging after a relevant recent x-ray when one or more red flags present (e.g., GCS<14, lack of eye opening, motor vehicle collision). Children ≥3: approve after a recent (within 60 days) x-ray when one or more red flags present (e.g., altered mental status, focal neurologic findings, neck pain, new torticollis, substantial torso injury, diving/head-first injury, high-speed MVC, predisposing conditions such as Down syndrome). Do NOT image children older than 2 when all low-risk criteria are met.60 days for children ≥3
See source for full red-flag definitions.
Thoracolumbar imaging following x-ray: Approve thoracolumbar advanced imaging when recent x-rays are inconclusive or when there is an abnormal neurologic examination.
Unit of service definitionThe unit of service for guidance codes is the individual encounter (date of service).
Applies to modalitiesApplies to CT, MR, US, and fluoroscopic guidance codes listed in guideline (77013, 77022, 77012, 77021, 76942, 77002-77003).
Age threshold for pediatric guideline applicability
Pediatric guideline age cutoffPatients age ≤18 years should be imaged according to the Pediatric Spine Imaging Guidelines.
AdultsIndividuals >18 years follow the General Spine Imaging Guidelines unless a pediatric section applies.
Reference sectionPediatric Spine Imaging Age Considerations (PEDSP-1.1).
X‑ray recency for cervical spine (children ≥3 years)
Cervical x-ray recency for children ≥3A recent plain cervical spine x-ray performed within 60 days is required to be available to the requesting provider before approving advanced cervical imaging in children ≥3 years when red flags are present.
Children under 3Children under 3 require a relevant recent x-ray (timing per clinical context) prior to advanced imaging when red flags present.
Denial riskAdvanced cervical imaging may be denied if required recent plain x-rays are not available to the requesting provider.
Age threshold for spinal ultrasound
Spinal ultrasound age limitSpinal canal ultrasound (CPT 76800) is generally limited to infants ≤6 months of age (corrected age for premature infants).
ExceptionPersistent posterior spinal defects creating an acoustic window may allow ultrasound at older ages when clinically appropriate.
Follow-upIf cord termination is uncertain in a premature infant, repeat spinal ultrasound can be performed in 4–6 weeks.
Prior Authorization
Prior authorization for 3D rendering codes
CPT 76376 and 76377 require documentation of physician supervision/participation for 3D post-processing and image rendering. UnitedHealthcare may require prior authorization for these 3D rendering codes even when the underlying imaging procedure (e.g., ultrasound or echocardiography) does not require prior authorization.
Document active physician participation per ACR recommendations.
CPT 76376: no independent workstation required.
CPT 76377: requires independent workstation.
Prior Authorization
Prior authorization / reporting headline
When PET-CT criteria are met but PET-CT is unavailable or PET-MRI is requested in lieu of PET-CT, PET-MRI may be appropriate and should be reported as the code combination CPT 78813 + CPT 76498. Diagnostic MRI codes may also be reported when clinically appropriate.
Report PET-MRI using CPT 78813 + CPT 76498 only when PET-CT criteria are met or PET-CT is unavailable.
Documentation Required
Consideration for combined MRI with/without contrast during single anesthesia
For pediatric MRI performed under a single anesthesia session, obtain all indicated sequences (with and/or without contrast) during that single session when clinically appropriate to minimize repeat anesthesia exposure. If IV access is present for anesthesia and no contraindication to contrast exists, consider obtaining both non-contrast and contrast-enhanced imaging if supported by the applicable guideline section.
Plan MRI of multiple body areas in the same anesthesia session when supported by guidelines.
Prior Authorization
Prior authorization conditional on x-ray and red flags / conservative therapy
Advanced imaging approvals for spine conditions generally require recent plain radiography and supporting clinical documentation. Approvals are contingent on availability of the plain x-ray results performed after the current episode of symptoms started or changed (or within 60 days for certain pediatric cervical indications). Advanced cervical spine imaging in children ≥3 years requires x-ray results within 60 days when indicated; lack of required recent plain x-rays may result in denial.
Requesting provider must have plain x-rays performed after current episode onset/ change.
For pediatric cervical spine (children ≥3 years), x-ray within 60 days is required when red flags present.
Prior Authorization
Conservative treatment trial requirement for children ≥6
For children ≥6 years with back or neck pain and no red flags, advanced imaging may be approved only after a recent (within 3 months) 4‑week trial of provider-supervised conservative treatment. Children evaluated by a pediatric spine surgeon may be assumed to have failed an adequate trial of conservative care.
A 4-week trial of provider-supervised conservative treatment is required in absence of red flags.
Red flags (see guideline) allow imaging without trial.
Documentation Required
Ultrasound before MRI in infants when appropriate
Spinal ultrasound (CPT 76800) is the preferred initial advanced imaging study for infants up to 6 months of age (including premature infants using corrected age ≤6 months) when evaluating for occult spinal dysraphism or related cutaneous indications. MRI is preferred for midline masses and for patients older than 6 months, or sooner when ultrasound is abnormal or when ordered by an appropriate specialist.
CPT 76800 may be approved as initial evaluation in infants ≤6 months (corrected age).
MRI indicated for midline masses and for >6 months of age or abnormal ultrasound.
Documentation Required
Postoperative MRI documentation
Postoperative spinal MRI is not performed routinely but may be approved when recurrent symptoms or findings suggest recurrent tethering or other deterioration. The ordering specialist should determine contrast use and document clinical rationale for postoperative imaging.
Postoperative MRI indicated for recurrent symptoms or signs suggestive of recurrent tethering.
Specify contrast level per ordering specialist.
Billing Rule
Single unit guidance code per encounter
Only one unit of radiologic guidance codes (e.g., CPT 77013, 77022, 76942, 77012/77021, 77002-77003) should be reported per individual encounter (date of service). The unit of service is the encounter, not the number of lesions, biopsies, injections, or localizations.
Report a single unit of the applicable guidance code per encounter.
Documentation Required
Submit recent detailed history, physical
Providers must submit adequate clinical information to establish medical necessity for advanced imaging. Required documentation includes a recent detailed history, physical exam (including a thorough neurologic exam when applicable), pertinent labs, and prior imaging studies. Failure to provide adequate information may result in denial.
Include recent detailed history and physical exam since onset/change in symptoms.
Provide neurologic exam results, labs, and prior imaging when applicable.
Note
Verify applicable benefit requirements
Verify applicable benefit, federal, state (Ohio Administrative Code), or contractual requirements before using this policy. In the event of conflict, federal, state (OAC), or contractual requirements govern and override this policy.
Check member benefit plan and OAC 5160-1-01 for coverage or quantity limits.
InterQual is used for primary medical/surgical criteria; if not applicable, other UnitedHealthcare policies may be used.
Applies to listed guidance codes
Applies to codes such as 77013, 77022, 77012, 77021, 76942, and fluoroscopy guidance codes 77002/77003.
Unit is encounter‑basedThe unit of service reflects the encounter, not the number of lesions, aspirations, biopsies, injections, or localizations performed during that encounter.
CT — sequences/slices guidance
No sequence/slice minimumThe AMA CPT manual does not define any minimum or maximum number of sequences or slices for CT CPT codes; no specific number is required for coding.
Use of CPT 76380CPT 76380 describes limited or follow‑up CT scans when a full diagnostic code is not performed; it is inappropriate to use 76380 with other diagnostic CT codes to cover extra slices.
Protocol drivenCT protocol selection (number of slices/sequences) should be guided by clinical need and individualized patient circumstances.
Any advanced imaging — repeat imaging criteria
Repeat imaging justificationRepeat advanced imaging should be performed only for disease progression, new onset of disease, or when the repeat study will affect clinical management or treatment decisions.
Preoperative imaging caveatPreoperative or preprocedural imaging should only be approved if the underlying surgery/procedure is indicated or has been approved; imaging is not justified solely to support an unindicated procedure.
Documentation requirementRequests for repeat imaging should include documentation that the results will change management (e.g., clinical deterioration, new findings).
Any advanced imaging — x‑ray prerequisite for pediatric cervical imaging
Cervical x‑ray within 60 days for children ≥3For cervical imaging in children ≥3 years, a recent plain x‑ray within 60 days of the request must be available to the requesting provider prior to approval of advanced imaging when indicated.
Thoracolumbar x‑ray prerequisiteFor thoracolumbar advanced imaging, recent x‑rays should be available and advanced imaging is approved when x‑rays are inconclusive or neurological exam is abnormal.
Exception for urgent casesIn cases of suspected abuse, trauma with red flags, or urgent clinical indications, imaging may be approved per clinical judgment with appropriate documentation.
Retroperitoneal ultrasound follow‑up intervalComplete retroperitoneal ultrasound (CPT 76770) may be approved every 6 to 12 months for follow‑up/surveillance of neurogenic bladder, myelomeningocele, or occult spinal dysraphism.
Use case examplesSame 6–12 month interval applies to retroperitoneal ultrasound used for bladder follow‑up in patients with spinal dysraphism or myelomeningocele.
Specialist directionFrequency should be tailored to clinical status and specialist recommendations; document clinical rationale for surveillance interval.
MRI without and with contrast — surveillance interval
Hemangioblastoma surveillance intervalMRI (without and with contrast) of the affected spinal level may be approved annually for asymptomatic patients with unresected spinal hemangioblastoma(s).
Indications for sooner imagingPerform MRI sooner for preoperative planning or if new or worsening symptoms suggest lesion progression.
Contrast levelMRI without and with contrast is acceptable for surveillance and surgical planning per guideline recommendations.
Note
Note
Advanced imaging to screen asymptomatic individuals for spine disorders is not supported and is a not-covered use of imaging resources.
CT performed solely to avoid the need for sedation in place of MRI is not appropriate when MRI is the preferred study; a CT may only replace MRI when specifically indicated in a guideline or when MRI is contraindicated.
Plain radiographs are not indicated for suspected occult spinal dysraphism or tethered cord and therefore are not a covered primary diagnostic step in that context.
Plain x-rays are not indicated for suspected occult spinal dysraphism/tethered cord; incidental spina bifida occulta on x-ray in an asymptomatic individual does not justify further imaging and is not covered as an indication.
These modalities are most often performed in initial and subsequent evaluations; advanced imaging is considered when initial studies are inconclusive.
Contrast selectionAppropriate contrast level for studies (none, with, or without and with) is determined by condition‑specific guideline sections.
PET/CT unbundling — policy
PET/CT unbundling stanceUnbundling PET/CT into separate PET and diagnostic CT CPT codes is not supported because PET/CT is performed as a single combined study.
PET/MRI notePET/MRI is generally not supported except in limited circumstances outlined in the guideline (see PET‑MRI section).
Reporting guidanceWhen PET‑MRI is appropriate and PET‑CT criteria are met or PET‑CT is unavailable, report using CPT 78813 (PET WB) combined with CPT 76498 (MRI unlisted) as indicated in prior‑auth guidance.
Concurrent supervision — definition
Concurrent supervision definitionConcurrent supervision requires active physician participation in and monitoring of the 3D reconstruction process, including selection of anatomy, tissues displayed, images archived, and adjustment of the 3D work product.
Documentation expectationACR recommends documenting the physician's supervision or participation in 3D reconstruction of images.
Applies to codesApplies to CPT 76376 and 76377 which describe 3D rendering procedures.
Unlisted CT/MR reporting guidanceReport CPT 76497 (unlisted CT) or CPT 76498 (unlisted MR) when no anatomic site‑specific CPT exists; use a Category III code if available instead of an unlisted code.
Use casesUnlisted codes may be appropriate for navigation/planning (e.g., Stealth/Brain Lab), custom arthroplasty planning, or procedures requiring different positional acquisition or thinner cuts than diagnostic studies.
Include documentationWhen using unlisted codes, include clinical rationale and description of the procedure elements that lack a specific CPT code.
Radiologic guidance codes — unit of service
Guidance codes unit of serviceRadiologic guidance codes (e.g., CPT 77013, 77022, 77012, 76942, 77002‑77003) represent guidance per individual encounter and only one unit should be reported per date of service.
Not per lesionUnit is not based on number of lesions, aspirations, biopsies, injections, or localizations performed during the encounter.
Billing riskBilling multiple units of these guidance codes for a single encounter may be considered inappropriate and risk denial.
Pediatric population — guideline assignment
Pediatric population definitionPatients ≤18 years should be imaged according to Pediatric Spine Imaging Guidelines; individuals >18 years follow General Spine Imaging Guidelines.
Applicability noteConditions not discussed in pediatric guidelines should follow general guidelines for adults.
Documentation expectationPertinent clinical evaluation must be available prior to advanced imaging in pediatric patients per guideline sections.
GBCA use limitationLimit use of gadolinium‑based contrast agents (GBCA) to situations where contrast provides necessary diagnostic information; assess necessity of repetitive GBCA MRIs.
Anesthesia considerationIf IV access is present for anesthesia and no contraindication exists, obtain both non‑contrast and contrast MRI sequences in the same session when appropriate to avoid repeat anesthesia.
Clinical scenarios for contrastMRI with and without contrast is indicated for infection, mass lesion suspicion, or new/worsening cancer‑related pain as described in condition‑specific sections.
Spinal canal ultrasound — CPT 76800
Spinal canal ultrasound CPTSpinal canal ultrasound is reported with CPT 76800.
Use limitationsDo not report CPT 76800 multiple times for different spinal canal areas; do not use 76800 for intraoperative ultrasound (use CPT 76998 instead).
Age limitationGenerally limited to infants up to 6 months due to acoustic window loss with ossification.
Spondylolysis — definition and clinical relevance
Spondylolysis definitionSpondylolysis is a stress fracture of the pars interarticularis typically due to repetitive microtrauma and is a common cause of low back pain in children >10.
Clinical relevanceImaging strategy includes screening with plain x‑rays, MRI for persistent symptoms after conservative care, and SPECT/SPECT‑CT or CT for radiographically occult or preoperative planning.
Preferred modalitiesMRI without contrast for symptomatic evaluation; SPECT (78803) or SPECT/CT (78830) for occult stress reaction; CT without contrast for detailed bony anatomy when needed.
Normal conus medullaris position — age milestones
Normal conus position by ageIn newborns the conus should terminate at L2‑3 or higher; by 3 months it should be at or above L2; thereafter at L1‑2. Premature infants may have a lower conus (mid L3).
Clinical milestoneBy 3 months of age the conus should be at or above the L2 level; findings below this warrant further evaluation for tethering.
Follow‑up ultrasound timingIf cord termination is uncertain in premature infants, repeat spinal ultrasound in 4–6 weeks to assess cranial migration of the conus.
Tethered Cord Syndrome — summary
Tethered Cord Syndrome summaryTethered Cord Syndrome refers to symptoms and abnormal findings (low back/leg pain, decreased lower extremity reflexes, urinary or bowel dysfunction) caused by pathologic attachment producing abnormal spinal tension.
Association with conus positionSome patients have abnormally low conus medullaris, but not all anatomically tethered cords produce symptoms.
Imaging implicationMRI of the appropriate spinal level is indicated when clinical signs suggest tethered cord; ultrasound is initial test in infants ≤6 months.
Tethered Cord Syndrome — symptoms and findings
Tethered Cord — symptoms and findingsSymptoms include low back/leg pain, decreased/absent lower extremity reflexes, urinary urgency/incontinence, bowel dysfunction and constipation; physical findings reflect pathologic attachment increasing spinal tension.
Diagnostic noteImaging selection depends on age and clinical findings; ultrasound for infants ≤6 months and MRI for older infants/children or abnormal ultrasound.
Not all tethering symptomaticNot all anatomical tethering results in symptomatic Tethered Cord Syndrome; clinical correlation required.
Spinal dysraphism — definition
Spinal dysraphism definitionSpinal dysraphism comprises congenital spinal malformations categorized as open (neural elements exposed) or closed (skin covered); clinically significant dysraphism ranges from vertebral anomalies to myelomeningocele.
Imaging implicationsMRI of the entire spine may be approved for preoperative planning; brain imaging (e.g., 70551/70553) indicated in open dysraphism for Chiari II evaluation.
Ultrasound useSpinal canal ultrasound (76800) may be an alternative to MRI in open dysraphism due to posterior bony defect providing an acoustic window.
Achondroplasia — MRI indicationAchondroplasia is a clinical diagnosis; MRI without contrast (or without and with) of the symptomatic spinal region can be approved when new or worsening symptoms suggest spinal stenosis.
Pre‑imaging requirementsPertinent clinical evaluation including detailed history, neurologic exam, and plain radiography should be performed prior to advanced imaging.
Brain imagingMRI brain (70551/70553) or CT head (70450) can be approved when symptoms suggest hydrocephalus in achondroplasia patients.
Atlantoaxial instability thresholdsInstability is identified when lateral cervical x‑ray shows an atlantodental interval ≥4.5 mm and/or neural canal width ≤14 mm.
Imaging actionMRI cervical spine without or without and with contrast (CPT 72141 or 72156) is indicated when these x‑ray thresholds are met or with new/worsening myelopathy symptoms.
Screening practiceTrisomy 21 patients are routinely screened with lateral cervical spine x‑rays per guideline recommendations.
Spinal hemangioblastoma surveillance (VHL) — frequency
Hemangioblastoma surveillance frequencyFor known unresected spinal hemangioblastomas (VHL), MRI of the affected spinal level may be performed annually for asymptomatic surveillance.
Other indicationsMRI is also indicated for preoperative planning and for new or worsening symptoms suggestive of progression.
Contrast recommendationMRI without and with contrast is appropriate for surveillance and preoperative planning of hemangioblastomas.
InterQual — primary determination source
Primary criteria sourceInterQual® is the primary medical/surgical criteria source used by UnitedHealthcare Services, Inc. for administering health benefits.
Fallback sourcesIf InterQual does not have applicable criteria, UnitedHealthcare may use its own Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines approved by the Ohio Department of Medicaid Services.
Coverage governanceFederal, state (OAC), or contractual benefit plan requirements govern in the event of conflict with this policy.