Spine Imaging Guidelines

This policy covers spine imaging—primarily advanced diagnostic imaging of the cervical, thoracic and lumbar spine (e.g., MRI/CT)—for conditions including neck, thoracic and low back pain, radiculopathy/neuropathy, myelopathy, spondylolysis/spondylolisthesis, spinal stenosis, SI joint disease, pathological compression fractures, cancer-related spinal pain and other spinal canal/cord disorders. Major requirements include an initial face-to-face clinical evaluation (within 60 days), documentation of failure of a recent six-week trial of provider-directed conservative therapy with clinical re-evaluation before advanced imaging, plain radiographs after the current episode when required, physician review for atypical presentations, and limited support for repeat/serial or simultaneous advanced studies without specific justification (e.g., preoperative planning).

"CT Pelvis without contrast (CPT 72192)"