This guideline addresses the use of computed tomography (CT) and magnetic resonance imaging (MRI) for evaluation, diagnosis, and management of spine-related conditions in the outpatient setting.

Note: Gadolinium is an essential part of the examination in certain clinical situations and is necessary for full evaluation in the examination of the spine postoperatively or in evaluation of infection or demyelinating diseases.

Note: When evaluating pain associated with neurologic deficit or radiculopathy unresponsive to non-surgical conservative treatment, MRI is generally preferred over CT.

Medically Necessary:
 
I.  Computed tomography (CT) or magnetic resonance imaging (MRI) of the Cervical Spine

The use of computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine is considered medically necessary when any of the following are present:

• Neck, shoulder, or upper extremity pain, with or without prior surgery, and documented focal neurologic deficit or abnormal findings on neurologic exam (i.e., motor weakness, dermatomal sensory loss, or significant reflex abnormality).
• Pain/radiculopathy in adults not improving despite 4 weeks of non-surgical treatment, which includes physical therapeutic modalities and appropriate pharmacologic intervention.  The 4-week requirement for treatment need not be applied to the pediatric patient or to those with documented rheumatologic disease with joint involvement.
• Acutely in the setting of major trauma.
• Recent less severe trauma to the spine with abnormalities on neurologic exam or x-ray or persistent increasing localized neck, shoulder, or upper extremity pain.
• Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis involving the spine, spinal cord, or adjacent structures or spaces.
• Clinical suspicion ("Red Flags", see note below) of primary cervical spine cancer with symptoms and/or signs suggesting involvement of the spine, spinal cord, meninges or positive bone scan in systemic processes.
• Known diagnosis of cancer with suspicion of metastases to the cervical spine, meninges, or spinal cord.
• Further investigation of spinal abnormality of unknown or uncertain cause seen on plain film.
• Clinical suspicion of cervical myelopathy or cervical nerve root compression with new onset of extremity weakness, bladder/bowel symptoms, ataxia, spasticity, spinal level sensory loss, etc.
• Signs/symptoms suggestive of spinal stenosis (weakness, spasticity, clonus, muscle wasting, generalized sensory loss, nerve root compression, hyperactive reflexes; suggestive x-ray findings).
• Significant scoliosis. For pediatric patients where imaging of the entire spine is needed an MRI may be more appropriate to minimize radiation exposure.
• Suspected spinal cord infarct or spinal cord tumor.
• In children, suspicion of congenital or acquired abnormalities of spine and/or spinal cord.
• MRI ONLY: To delineate the presence or absence of demyelinating disease.

II.  Computed tomography (CT) or magnetic resonance imaging (MRI) of the Thoracic Spine

The use of computed tomography (CT) or magnetic resonance imaging (MRI) of the thoracic spine is considered medically necessary when any of the following are present:

• Acute onset of thoracic back pain accompanied by weakness, autonomic dysfunction, significant reflex abnormality, or sensory loss documented by physical exam.
• Pain/radiculopathy in adults not improving despite 4 weeks of non-surgical conservative treatment which includes physical therapeutic modalities and appropriate pharmacologic intervention.  The 4-week requirement for treatment need not be applied to the pediatric patient or to those with documented rheumatologic disease with joint involvement.
• Acutely in the setting of major trauma.
• Recent less severe trauma to the spine with abnormal x-ray films or normal x-ray films with abnormal neurological exam OR persistent pain.
• Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis involving the thoracic spine, spinal cord or adjacent structures or spaces.
• Clinical suspicion ("Red Flags", see note below) of primary thoracic spine cancer with symptoms and/or findings suggesting involvement of the thoracic spine, spinal cord, meninges or positive bone scan.
• Known diagnosis of cancer with suspicion of metastases to the thoracic spine, meninges, or spinal cord.
• Clinical suspicion of lower extremity weakness, bladder/bowel symptoms, ataxia, spasticity, spinal level sensory loss, etc.
• Significant scoliosis. For pediatric patients where imaging of the entire spine is needed an MRI may be more appropriate to minimize radiation exposure.
• Suspected spinal cord infarct or spinal cord tumor.
• In children, suspicion of congenital or acquired abnormalities of spine and/or spinal cord.
• Further investigation of spinal abnormality of unknown or uncertain cause seen on plain film.
• Documented abnormality of the thoracic spine, which may require surgery or bracing (such as scoliosis).
• MRI ONLY: To delineate the presence or absence of demyelinating disease.

III.  Computed tomography (CT) or magnetic resonance imaging (MRI) of the Lumbar Spine

The use of computed tomography (CT) or magnetic resonance imaging (MRI) of the lumbar spine is considered medically necessary when any of the following are present:

• Leg pain with or without associated back pain and documented focal neurologic deficit (such as motor weakness, dermatomal sensory loss, or significant reflex abnormality).
• Pain/radiculopathy in adults not improving despite 4 weeks of non-surgical treatment, which includes physical therapeutic modalities and appropriate pharmacologic intervention.  The 4-week requirement for treatment need not be applied to the pediatric patient; or to those with documented rheumatologic disease with joint involvement.
• Acutely in the setting of major trauma.
• Recent less severe trauma to the spine with abnormalities on neurologic exam or abnormal x-ray or persistent localized pain.
• Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis involving the spine or spinal cord, spinal cord or adjacent structures or spaces.
• Clinical suspicion ("Red Flags", see note below) of primary lumbar spine cancer with symptoms and/or findings suggesting involvement of the spine, spinal cord, meninges or positive bone scan.
• Clinical suspicion of lumbar myelopathy or lumbar nerve root or cauda equina compression with extremity weakness, bladder/bowel symptoms, ataxia, spasticity, spinal level sensory loss.
• Suspected spinal cord (cones medularis) infarct or spinal (cauda equina) cord tumor.
• Significant scoliosis. For pediatric patients where imaging of the entire spine is needed an MRI may be more appropriate to minimize radiation exposure.
• In children, suspicion of congenital or acquired abnormalities of spine and/or cauda equina or tethered cord.
• Known diagnosis of cancer with suspicion of metastases to the lumbar spine, meninges, or spinal cord.
• Further investigation of spinal abnormality of unknown or uncertain cause seen on plain film.
• Findings consistent with cauda equina syndrome (bilateral sciatica, saddle anesthesia, bladder/bowel disturbance, etc.).
• Sign/symptoms suggestive of spinal stenosis (pseudoclaudication; pain/numbness/tingling with activity, relieved by rest, sitting, spinal flexion; suggestive x-ray findings).

Note: MRI is probably not medically necessary in adult patient with low back pain without neurological deficits AND without signs of serious disease or "red flags" (unexplained weight loss, fever, abnormal serum protein electrophoresis, history of malignant disease, elevated ESR, positive ANA, parenteral drug abuse, history of tuberculosis, etc.) unless surgery is being considered.

Clinical Considerations:

• The CT scan is frequently used for guidance for invasive procedures such as biopsy, implant or repair.
• Clinical situations may influence whether CT or MRI is suitable for pregnant women and children.
• Immunosuppressed individuals require a higher level of suspicion.
• Back and neck pain are less common in children and the requirement for 4 weeks of conservative treatment prior to imaging is not applicable to significant, unexplained back or neck pain in the pediatric patient.
• Individuals with rheumatoid arthritis are at increased risk for spinal misalignment and the requirement for 4 weeks of conservative treatment prior to imaging is not applicable to this group.
• Absolute or relative contraindications for scans requiring intravascular administration of contrast material may include individuals:
• Who have a documented allergy from prior contrast administration or a history of atopy.
• Who have impaired renal function, when considering an enhanced CT with intravascular iodinated contrast agents.
• Who have multiple myeloma.
• Contraindications for MRI imaging include individuals:
• Who have a pacemaker or implantable cardioverter-defibrillator (ICD).
• Who have intracranial surgical clips, that are not compatible with the use of MRI, placed for an aneurysm.
• Who have had placement of other non-MRI compatible devices within the body.
• Additional considerations and possible contraindications for MRI may also include individuals:
• Who have had placement of metal devices located in the area to be imaged.
• Whose condition requires external devices for care (e.g., portable O2 tank).
• Indications for open MRI imaging may include:
• Individuals who have had placement of small of implanted metal not located in the imaging area.
  
or
• Individuals who are claustrophobic.
• MRI is not appropriate as a screening tool (i.e., asymptomatic patients without a previous diagnosis cervical nerve root compression).
• Once a positive diagnosis of multiple sclerosis (MS) has been established, further diagnostic MRI scans of the cervical cord may prove useful in tracking the progress of the disease, establishing a prognosis or evaluating medication therapy. The frequency of repeat scans should be based on the patient’s status. Changes in neurologic signs and symptoms may require repeat imaging. Early in the course of the disease, periodic scans may be warranted to assess for asymptomatic progression if this information would be used to make treatment determinations. Repeat imaging of the thoracic spine in MS patients should be based on changes in the patient’s status.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

72125	Computed tomography, cervical spine; without contrast material
72126	Computed tomography, cervical spine, with contrast material
72127	Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections
72128	Computed tomography, thoracic spine; without contrast material
72129	Computed tomography, thoracic spine; with contrast material
72130	Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections
72131	Computed tomography, lumbar spine; without contrast material
72132	Computed tomography, lumbar spine; with contrast material
72133	Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections
72141	Magnetic resonance (eg, proton) imaging, spine canal and contents, cervical; without contrast material
72142	Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)
72146	Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material
72147	Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)
72148	Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material
72149	Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)
72156	Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical
72157	Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic
72158	Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar

88.38	Other computerized axial tomography (specified as spine)
88.93	Magnetic resonance imaging of spinal canal

0359	Computed tomographic (CT) scan, other (specified as spine)
0612	Magnetic resonance imaging, spinal cord

ICD-9 Diagnosis

	All diagnoses

Computed tomography (CT), sometimes called a CAT scan, is a diagnostic tool that uses special x-ray equipment to obtain image data from different angles around the body, then uses computer processing of the information to show a cross-section of body tissues and organs. The CT requires less time and can be performed in acute settings where advanced monitoring and life support is needed for an unstable patient.

Magnetic resonance imaging (MRI) is a diagnostic technique that uses a cylindrical magnet and radio waves to produce high quality multiplanar images of organs and structures within the body without x-rays or radiation. The body's hydrogen atoms react to the magnetic field and pulses of radio waves. This reaction is changed to an image by a computer. CT and MRI are valuable imaging techniques most often used when preliminary diagnostics or symptoms suggest an abnormal condition requiring further analysis.

1. American College of Radiology. ACR Appropriateness Criteria™: Follow-Up Examinations for Bone Tumors, Soft Tissue Tumors and Suspected Metastases. 2005. Available at: http://www.acr.org/s_acr/bin.asp?CID=1206&DID=11793&DOC=FILE.PDF. Accessed on March 23, 2007.
2. American College of Radiology. ACR Appropriateness Criteria™: Metastatic Bone Disease. 2005. Available at: http://www.acr.org/s_acr/bin.asp?CID=1206&DID=11781&DOC=FILE.PDF. Accessed on March 23, 2007.
3. American College of Radiology. ACR Appropriateness Criteria™: Cervical Spine trauma. 2005. Available at http://www.acr.org/s_acr/bin.asp?CID=1206&DID=11775&DOC=FILE.PDF. Accessed on March 23, 2007.
4. American College of Radiology. ACR Appropriateness Criteria™: Bone Tumors. 2005. Available at http://www.acr.org/s_acr/bin.asp?CID=1206&DID=11778&DOC=FILE.PDF. Accessed on March 23, 2007.
5. American College of Radiology. ACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Adult Spine (2003). Available at http://www.acr.org/s_acr/bin.asp?CID=542&DID=12249&DOC=FILE.PDF. Accessed on March 23, 2007.
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8. Centers for Medicare and Medicaid Services. National Coverage Determination for Magnetic Resonance Imaging (MRI). NCD #220.2. Effective March 22, 1994. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on March 23, 2007.
9. Deyo RA, Winstein JN. Low Back Pain. NEJM. 2001; 344(5):363-370.
10. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma. 2005; 58(5):902-905.
11. Kendrick D, Fielding K, Bentley E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial BMJ, 2001; 322(7283):400-405.
12. Patel AT, Ogle AA. Diagnosis and Management of Acute Low Back Pain. 2000; 61(6):1779-86, 1789-1790
13. Walter B, Snider RK, Eds. Essentials of Musculoskeletal Care, American College of Orthopedic Surgeons, Rosemont, IL. 2001
    

Back Pain
Cervical Spine
Computed Tomography (CT)
Lumbar Spine
Magnetic Resonance Imaging (MRI)
Multiple Sclerosis (MS)
Thoracic Spine

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