CG-SURG-29 Lumbar Discography

This policy addresses lumbar discography, an invasive diagnostic test involving pressure-controlled contrast injection into lumbar discs with CT imaging to assess discogenic low back pain. It is medically necessary only for unrelenting low back pain (with or without leg pain) persisting ≥3 months when conservative therapy has failed, noninvasive studies are inconclusive, and no contraindications are present (e.g., severe spinal stenosis causing intraspinal obstruction, infection, or predominantly psychogenic pain). It is not medically necessary if these criteria are not all met.

"Discography of thelumbarvertebrae is consideredmedically necessaryfor the evaluation of low back pain with or without lower extremity pain when ALL of the following are present:"

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