Spine Imaging Guidelines

This policy covers spine imaging—advanced diagnostic imaging such as MRI and CT of the cervical, thoracic, and lumbar spine (specified CPT codes)—for indications including neck, thoracic and low back pain, radiculopathy/plexopathy, myelopathy, spinal stenosis, spondylolysis/spondylolisthesis, sacro‑iliac/inflammatory sacroiliitis, pathological compression fractures, cancer‑related spinal pain, and other spinal canal/cord disorders. Major limitations require an initial face‑to‑face clinical evaluation within 60 days, documented clinical re‑evaluation with failure of a recent six‑week trial of provider‑directed conservative therapy (within the last 3 months) before advanced imaging is considered, while atypical presentations require physician review and repeat/serial or simultaneous studies are restricted or limited to documented preoperative/post‑myelography indications.

"Head trauma and/or maxillofacial trauma"