Spine Imaging Guidelines

This policy covers spine imaging—principally MRI/MRA (cervical, thoracic, lumbar and pelvic), CT, SPECT and MR spectroscopy (including targeted discogenic pain spectroscopy)—for evaluation of spinal disorders. It applies to patients with neck, thoracic or low back pain and related conditions (with or without neurologic features) such as radiculopathy, myelopathy, spinal stenosis, spondylolysis/spondylolisthesis, sacroiliitis/inflammatory disease, pathological compression fractures, cancer-related spinal pain and other spinal canal/cord disorders. Advanced imaging generally requires a recent face-to-face clinical evaluation (within 60 days), documentation of failure of a recent 6‑week trial of provider-directed conservative therapy with clinical re-evaluation, atypical presentations require physician review, and modality-specific limits (e.g., SPECT single-area per service; certain CT contrast codes tied to post-myelography/discography) apply.

"Documentation of clinical re-evaluation prior to consideration of advanced diagnostic imaging to show failure of significant clinical improvement."