ADVANCED IMAGING - AIM Specialty Health

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CLINICAL APPROPRIATENESS GUIDELINESADVANCED IMAGINGAppropriate Use Criteria: Imaging of the SpineEFFECTIVE SEPTEMBER 28, 2019ProprietaryApproval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details.AIM Specialty Health disclaims any responsibility for the completeness or accuracy of the information contained herein.8600 West Bryn Mawr AvenueSouth Tower – Suite 800 Chicago, IL fordable 2017 2019 AIM Specialty Health2057-0919

Imaging of the SpineTable of ContentsDescription and Application of the Guidelines.4General Clinical Guideline .5Clinical Appropriateness Framework . 5Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions . 5Repeat Diagnostic Intervention . 5Repeat Therapeutic Intervention . 6Imaging of the Spine .7General Information/Overview . 7Scope .7Technology Considerations .7Definitions.7Clinical Indications .9Congenital and Developmental Conditions . 10Chiari malformation . 10Congenital spinal cord anomalies not listed . 10Congenital vertebral defects . 10Craniocervical junction abnormalities . 10Scoliosis . 10Spinal dysraphism . 11Tethered cord . 12Infectious and Inflammatory Conditions . 12Juvenile idiopathic arthritis (Pediatric only). 12Multiple sclerosis or other white matter disease . 13Rheumatoid arthritis (Adult only) . 14Spinal infection . 14Spondyloarthropathy . 14Trauma . 15Cervical injury . 15Thoracic or lumbar injury . 17Tumor . 17Tumor . 17Miscellaneous Conditions of the Spine . 18Osteoporosis and osteopenia . 18Paget’s disease . 19Spinal cord infarction . 19Spondylolysis and spondylolisthesis . 19Spontaneous (idiopathic) intracranial hypotension (SIH) . 19Syringomyelia . 20Perioperative and Periprocedural Imaging . 20Perioperative Imaging, including delayed hardware failure, not otherwise specified . 20Copyright 2019. AIM Specialty Health. All Rights Reserved.2

Imaging of the SpineSigns and Symptoms . 20Cauda equina syndrome . 20Myelopathy . 20Pain indications . 21Neck pain (cervical) . 21Mid-back pain (thoracic) . 22Low back pain (lumbar) . 22References . 24Codes . 28History. 29Copyright 2019. AIM Specialty Health. All Rights Reserved.3

Imaging of the SpineDescription and Application of the GuidelinesThe AIM Clinical Appropriateness Guidelines (hereinafter “the AIM Clinical Appropriateness Guidelines” orthe “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for aspecific clinical condition for an individual. As used by AIM, the Guidelines establish objective andevidence-based criteria for medical necessity determinations where possible. In the process, multiplefunctions are accomplished: To establish criteria for when services are medically necessary To assist the practitioner as an educational tool To encourage standardization of medical practice patterns To curtail the performance of inappropriate and/or duplicate services To advocate for patient safety concerns To enhance the quality of health care To promote the most efficient and cost-effective use of servicesThe AIM guideline development process complies with applicable accreditation standards, including therequirement that the Guidelines be developed with involvement from appropriate providers with currentclinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinicalprinciples and best practices. Relevant citations are included in the References section attached to eachGuideline. AIM reviews all of its Guidelines at least annually.AIM makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week.Copies of the AIM Clinical Appropriateness Guidelines are also available upon oral or written request.Although the Guidelines are publicly-available, AIM considers the Guidelines to be important, proprietaryinformation of AIM, which cannot be sold, assigned, leased, licensed, reproduced or distributed withoutthe written consent of AIM.AIM applies objective and evidence-based criteria, and takes individual circumstances and the localdelivery system into account when determining the medical appropriateness of health care services. TheAIM Guidelines are just guidelines for the provision of specialty health services. These criteria aredesigned to guide both providers and reviewers to the most appropriate services based on a patient’sunique circumstances. In all cases, clinical judgment consistent with the standards of good medicalpractice should be used when applying the Guidelines. Guideline determinations are made based on theinformation provided at the time of the request. It is expected that medical necessity decisions maychange as new information is provided or based on unique aspects of the patient’s condition. The treatingclinician has final authority and responsibility for treatment decisions regarding the care of the patient andfor justifying and demonstrating the existence of medical necessity for the requested service. TheGuidelines are not a substitute for the experience and judgment of a physician or other health careprofessionals. Any clinician seeking to apply or consult the Guidelines is expected to use independentmedical judgment in the context of individual clinical circumstances to determine any patient’s care ortreatment.The Guidelines do not address coverage, benefit or other plan specific issues. Applicable federal andstate coverage mandates take precedence over these clinical guidelines. If requested by a health plan,AIM will review requests based on health plan medical policy/guidelines in lieu of the AIM Guidelines.The Guidelines may also be used by the health plan or by AIM for purposes of provider education, or toreview the medical necessity of services by any provider who has been notified of the need for medicalnecessity review, due to billing practices or claims that are not consistent with other providers in terms offrequency or some other manner.Copyright 2019. AIM Specialty Health. All Rights Reserved.4

Imaging of the SpineGeneral Clinical GuidelineClinical Appropriateness FrameworkCritical to any finding of clinical appropriateness under the guidelines for a specific diagnostic ortherapeutic intervention are the following elements: Prior to any intervention, it is essential that the clinician confirm the diagnosis or establish its pretestlikelihood based on a complete evaluation of the patient. This includes a history and physicalexamination and, where applicable, a review of relevant laboratory studies, diagnostic testing, andresponse to prior therapeutic intervention. The anticipated benefit of the recommended intervention should outweigh any potential harms thatmay result (net benefit). Current literature and/or standards of medical practice should support that the recommendedintervention offers the greatest net benefit among competing alternatives. Based on the clinical evaluation, current literature, and standards of medical practice, there exists areasonable likelihood that the intervention will change management and/or lead to an improvedoutcome for the patient.If these elements are not established with respect to a given request, the determination ofappropriateness will most likely require a peer-to-peer conversation to understand the individual andunique facts that would supersede the requirements set forth above. During the peer-to-peerconversation, factors such as patient acuity and setting of service may also be taken into account.Simultaneous Ordering of Multiple Diagnostic or Therapeutic InterventionsRequests for multiple diagnostic or therapeutic interventions at the same time will often require a peer-topeer conversation to understand the individual circumstances that support the medical necessity ofperforming all interventions simultaneously. This is based on the fact that appropriateness of additionalintervention is often dependent on the outcome of the initial intervention.Additionally, either of the following may apply: Current literature and/or standards of medical practice support that one of the requested diagnosticor therapeutic interventions is more appropriate in the clinical situation presented; or One of the diagnostic or therapeutic interventions requested is more likely to improve patientoutcomes based on current literature and/or standards of medical practice.Repeat Diagnostic InterventionIn general, repeated testing of the same anatomic location for the same indication should be limited toevaluation following an intervention, or when there is a change in clinical status such that additionaltesting is required to determine next steps in management. At times, it may be necessary to repeat a testusing different techniques or protocols to clarify a finding or result of the original study.Repeated testing for the same indication using the same or similar technology may be subject toadditional review or require peer-to-peer conversation in the following scenarios: Repeated diagnostic testing at the same facility due to technical issues Repeated diagnostic testing requested at a different facility due to provider preference or qualityconcerns Repeated diagnostic testing of the same anatomic area based on persistent symptoms with noclinical change, treatment, or intervention since the previous study Repeated diagnostic testing of the same anatomic area by different providers for the same memberover a short period of timeCopyright 2019. AIM Specialty Health. All Rights Reserved.5

Imaging of the SpineRepeat Therapeutic InterventionIn general, repeated therapeutic intervention in the same anatomic area is considered appropriate whenthe prior intervention proved effective or beneficial and the expected duration of relief has lapsed. Arepeat intervention requested prior to the expected duration of relief is not appropriate unless it can beconfirmed that the prior intervention was never administered.Copyright 2019. AIM Specialty Health. All Rights Reserved.6

Imaging of the SpineImaging of the SpineGeneral Information/OverviewScopeThese guidelines address advanced imaging of the spine in both adult and pediatric populations. Forinterpretation of the guidelines, and where not otherwise noted, “adult” refers to persons age 19 and older,and “pediatric” refers to persons age 18 and younger. Where separate indications exist, they are specifiedas Adult or Pediatric. Where not specified, indications and prerequisite information apply to persons of allages.See the Coding section for a list of modalities included in these guidelines.Technology ConsiderationsAdvanced imaging is an umbrella term that refers to anatomy-based (structural), physiology-based(functional), and hybrid imaging methods that offer greater spatial and/or contrast resolution relative toconventional imaging methods in radiology such as radiography or ultrasound. Examples of advancedstructural imaging include computed tomography (CT), magnetic resonance imaging (MRI), and sometechnique variants. Advanced functional imaging includes positron emission tomography (PET), as well asthose MRI/CT technique variants that create image contrast based on a physiological parameter (forexample, functional magnetic resonance imaging (fMRI). Hybrid advanced imaging techniques optimizediagnostic accuracy by coupling structural and functional approaches (such as PET-CT or PET-MRI).Computed tomography (CT) is the preferred imaging modality for bony abnormalities of the spine whenradiographs do not provide sufficient detail for management. Common indications include fracture,vertebral anomalies, and osseous tumors.Spine CT is also utilized for CT myelography, in which radiographically opaque dye is injected into thethecal sac to image nerve detail. CT myelography is invasive, but is comparable to MRI in detection ofneural impingement and stenosis, and can also be used in diagnosis of cerebrospinal fluid leak and nerveroot avulsion. Conventional myelography, in which radiographs are obtained rather than using CTimaging, is less commonly performed.Disadvantages of CT include exposure to ionizing radiation and risks associated with iodinated contrast,including allergy and impaired renal function.Magnetic resonance imaging (MRI) is the preferred modality for the majority of soft tissue indications inthe spine due to its superior resolution and lack of ionizing radiation. MRI can be performed with orwithout contrast; contrast may be necessary for infection, tumor, and post-surgical evaluation. ContrastMRI may also be useful for imaging herniated discs—particularly if herniation needs to be distinguishedfrom post-surgical epidural scarring—and diagnosing tumors in the intramedullary, extramedullary, andextradural spaces.Contraindications to MRI may include implanted devices unsafe for use in an MRI scanner—such aspacemakers or implantable cardioverter-defibrillators—and claustrophobia.CT discography determines the available volume of discs and can be used to localize annulus fibrosisfissures or herniated discs. Discography can also confirm the source of back pain by reproducing thesymptoms associated with disc herniation. MR discography may be performed in the event that CT iscontraindicated. False positives, infection, and neural injury are possible with discography, and it shouldbe used primarily to confirm an initial diagnosis.DefinitionsPhases of the car

Advanced imaging is an umbrella term that refers to anatomy-based (structural), physiology-based (functional), and hybrid imaging methods that offer greater spatial and/or contrast resolution relative to conventional imaging methods in radiology such as radiography or ultrasound. Examples of advanced

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