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CLINICAL GUIDELINESSpine Imaging PolicyVersion 1.0.2019Effective February 15, 2019eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individualswith atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/orindividual’s Primary Care Physician (PCP) may provide additional insight.CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT five digit codes, nomenclature and other dataare copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT book.AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. 2019 eviCore healthcare. All rights reserved.

Imaging GuidelinesV1.0.2019Spine Imaging GuidelineseviCore Code Management for BCBS AL3Procedure Codes Associated with Spine Imaging4SP-1: General Guidelines5SP-2: Imaging Techniques14SP-3: Neck (Cervical Spine) Pain Without/With NeurologicalFeatures (Including Stenosis) and Trauma22SP-4: Upper Back (Thoracic Spine) Pain Without/With NeurologicalFeatures (Including Stenosis) and Trauma26SP-5: Low Back (Lumbar Spine) Pain/Coccydynia withoutNeurological Features29SP-6: Lower Extremity Pain with Neurological Features(Radiculopathy, Radiculitis, or Plexopathy and Neuropathy) With orWithout Low Back (Lumbar Spine) Pain33SP-7: Myelopathy37SP-8: Lumbar Spine Spondylolysis/Spondylolisthesis40SP-9: Lumbar Spinal Stenosis43SP-10: Sacro-Iliac (SI) Joint Pain, InflammatorySpondylitis/Sacroiliitis and Fibromyalgia45SP-11: Pathological Spinal Compression Fractures48SP-12: Spinal Pain in Cancer Patients50SP-13: Spinal Canal/Cord Disorders (e.g. Syringomyelia51SP-14: Spinal Deformities (e.g. Scoliosis/Kyphosis53SP-15: Post-Operative Spinal Disorders56SP-16: Other Imaging Studies and Procedures Related to the SpineImaging Guidelines59SP-17: Nuclear Medicine63 2019 eviCore healthcare. All Rights Reserved.Page 2 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.com

Imaging GuidelinesV1.0.2019eviCore Code Management for BCBS ALThe code list below is a comprehensive list of all the codes within this policy that are inscope for BCBSAL. Codes may be located in more than one policy of the ImagingGuidelines. Please refer to the policy specific list, located at the top of each policy, todetermine if the code is in scope.Requires Prior AuthorizationCode DescriptionCTA of the HeadMRI of the Brain w/o GadoliniumMRI Head w/ GadoliniumCT Cervical Spine w/o ContrastCT Cervical Spine w/ ContrastCT Cervical Spine w/o and w/ ContrastCT of the Thoracic Spine w/o ContrastCT of the Thoracic Spine w/ ContrastCT of the Thoracic Spine w/o and w/ ContrastCT of the Lumbar Spine w/o ContrastCT of the Lumbar Spine w/ ContrastCT of the Lumbar Spine w/o and w/ ContrastMRI Cervical Spine w/o GadoliniumMRI of the Cervical Spine W/ GadoliniumMRI Thoracic Spine w/o ContrastMRI Thoracic Spine w/ GadoliniumMRI Lumbar Spine w/o GadoliniumMRI Lumbar Spine w/ GadoliniumMRI of the Cervical Spine w/ and w/o GadoliniumMRI Thoracic Spine w/ and w/o GadoliniumMRI Lumbar Spine w/ and w/o GadoliniumMRA of the Spinal CanalCTA of the PelvisCT of the Pelvis w/o ContrastCT of the Pelvis w/ ContrastCT of the Pelvis w/o and w/ ContrastMRI of the Pelvis w/o GadoliniumMRI of the Pelvis w/ and w/o GadoliniumMRA or MRV Of The Pelvis w/o or w/ GadoliniumCTA of the AbdomenMRA of the Abdomen w/o or w/ GadoliniumMedicareL34415L34415L34415 2019 eviCore healthcare. All Rights Reserved.Page 3 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comSpine ImagingCPT 417574185

Imaging GuidelinesV1.0.2019CPT 721957219672197CPT 7219372194CPT 76800CPT 78807 2019 eviCore healthcare. All Rights Reserved.Page 4 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comSpine ImagingProcedure Codes Associated with Spine ImagingMRI/MRACervical MRI without contrastCervical MRI with contrastCervical MRI without and with contrastThoracic MRI without contrastThoracic MRI with contrastThoracic MRI without and with contrastLumbar MRI without contrastLumbar MRI with contrastLumbar MRI without and with contrastSpinal Canal MRAMRI Pelvis without contrastMRI Pelvis with contrastMRI Pelvis without and with contrastCTCervical CT without contrastCervical CT with contrast (Post-Myelography CT)Cervical CT without and with contrastThoracic CT without contrastThoracic CT with contrast (Post-Myelography CT)Thoracic CT without and with contrastLumbar CT without contrast (Post-Discography CT)Lumbar CT with contrast (Post-Myelography CT)Lumbar CT without and with contrastCT Pelvis without contrastCT Pelvis with contrastCT Pelvis without and with contrastUltrasoundSpinal canal ultrasoundNuclear MedicineBone Marrow Imaging, LimitedBone Marrow Imaging, MultipleBone Marrow Imaging, Whole BodyBone or Joint Imaging, LimitedBone or Joint Imaging, MultipleBone Scan, Whole BodyBone Scan, 3 Phase StudyBone Joint Imaging Tomo Test SPECTRadiopharmaceutical Localization of Abscess, Limited AreaRadiopharmaceutical Localization of Abscess, Whole BodyRadiopharmaceutical Localization of Abscess, tomographic (SPECT)

Imaging GuidelinesV1.0.2019SP-1: General GuidelinesSP-1.1: General ConsiderationsSP-1.2: Red Flag IndicationsSP-1.3: Definitions6912 2019 eviCore healthcare. All Rights Reserved.Page 5 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.com

Imaging GuidelinesV1.0.2019SP-1.1: General Considerations Before advanced diagnostic imaging can be considered, there must be an initialface-to-face clinical evaluation as well as a clinical re-evaluation after a trial of failedconservative therapy; the clinical re-evaluation may consist of a face-to-faceevaluation or other meaningful contact with the provider’s office such as email, webor telephone communications. A face-to-face clinical evaluation is required to have been performed within the last60 days before advanced imaging is considered. This may have been either theinitial clinical evaluation or a clinical re-evaluation. The initial clinical evaluation should include a relevant history and physicalexamination (including a detailed neurological examination), appropriate laboratorystudies, non-advanced imaging modalities, results of manual motor testing, thespecific dermatomal distribution of altered sensation, reflex examination, and nerveroot tension signs (e.g., straight leg raise test, slump test, femoral nerve tensiontest). The initial clinical evaluation must be face-to-face; other forms of meaningfulcontact (telephone call, electronic mail or messaging) are not acceptable as an initialevaluation. For those spinal conditions/disorders for which the Spine Imaging Guidelinesrequire a plain x-ray of the spine prior to consideration of an advanced imagingstudy, the plain x-ray must be performed after the current episode of symptomsstarted or changed (see SP-2.1: Anatomic Guidelines). Any bowel/bladder abnormalities or emergent or urgent indications should bedocumented at the time of the initial clinical evaluation and clinical re-evaluation. Altered sensation to pressure, pain, and temperature should be documented by thespecific anatomic distribution (e.g., dermatomal, stocking/glove or mixeddistribution). Motor deficits (weakness) should be defined by the specific myotomal distribution(e.g., weakness of toe flexion/extension, knee flexion/extension, ankle dorsi/plantar 2019 eviCore healthcare. All Rights Reserved.Page 6 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comSpine Imaging Clinical re-evaluation is required prior to consideration of advanced diagnosticimaging to document failure of significant clinical improvement following a recent(within 3 months) six week trial of provider-directed treatment. Clinical re-evaluationcan include documentation of a face-to-face encounter or documentation of othermeaningful contact with the requesting provider’s office by the patient (e.g.,telephone call, electronic mail or messaging). Provider-directed treatment may include education, activity modification, NSAIDs(non-steroidal anti-inflammatory drugs), narcotic and non-narcotic analgesicmedications, oral or injectable corticosteroids, a provider-directed homeexercise/stretching program, cross-training, avoidance of aggravating activities,physical/occupational therapy, spinal manipulation, interventional painprocedures and other pain management techniques.

Imaging Guidelines012345V1.0.2019flexion, wrist dorsi/palmar flexion) and gradation of muscle testing should bedocumented as follows:Grading of Manual Muscle TestingNo evidence of muscle functionMuscle contraction but no or very limited joint motionMovement possible with gravity eliminatedMovement possible against gravityMovement possible against gravity with some resistanceMovement possible against gravity with full or normal resistance Pathological reflexes (e.g. Hoffmann’s, Babinski, and Chaddock sign) should bereported as positive or negative. Asymmetric reflexes and reflex examination should be documented as follows:Grading of Reflex Testing01 2 3 4 No responseA slight but definitely present responseA brisk responseA very brisk response without clonusA tap elicits a repeating reflex (clonus) Advanced diagnostic imaging is often urgently indicated and may be necessary ifserious underlying spinal and/or non-spinal disease is suggested by the presence ofcertain patient factors referred to as “red flags.” See SP-1.2: Red Flag Indications. Spinal specialist evaluation can be helpful in determining the need for advanceddiagnostic imaging, especially for patients following spinal surgery. Serial advanced imaging, whether CT or MRI, for surveillance of healing or recoveryfrom spinal disease is not supported by the currently available scientific evidencebased medicine for the majority of spinal disorders. Advanced imaging is generally unnecessary for resolved or improving spinal painand/or radiculopathy. For patients experiencing chronic spine pain, advanced diagnostic imaging has notbeen shown to be of value in patients with stable, longstanding spinal pain withoutneurological features or without clinically significant or relevant changes insymptoms or physical examination findings. 2019 eviCore healthcare. All Rights Reserved.Page 7 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comSpine Imaging The need for repeat advanced diagnostic imaging should be carefully consideredand may not be indicated if prior advanced diagnostic imaging has been performed.Requests for simultaneous, similar studies such as spinal MRI and CT need to bedocumented as required for preoperative surgical planning. These studies may behelpful in the evaluation of complex failed spinal fusion cases or needed forpreoperative surgical planning when the determination of both soft tissue and bonyanatomy is required.

Imaging GuidelinesV1.0.2019Practice NotesStraight leg raise test (also known as the Lasegue’s test) – With the patient in thesupine position, the hip medially rotated and adducted, and the knee extended, theexaminer flexes the hip until the patient complains of pain or tightness in the back orback of the leg. If the pain is primarily back pain, it is more likely a disc herniation or thepathology causing the pain is more central. If pain is primarily in the leg, it is more likelythat the pathology causing the pressure on neurological tissues is more lateral. Discherniation or pathology causing pressure between the two extremes are more likely tocause pain in both areas. The examiner then slowly and carefully drops the leg back(extends it) slightly until the patient feels no pain or tightness. The patient is then askedto flex the neck so the chin is on the chest, or the examiner may dorsiflex the patient’sfoot, or both actions may be done simultaneously. Both of these maneuvers areconsidered to be provocative tests for neurological tissue.Femoral nerve tension test (also known as the prone knee bending test) – The patientlies prone while the examiner passively flexes the knee as far as possible so that thepatient’s heel rests against the buttock. At the same time, the examiner should ensurethat the patient’s hip is not rotated. If the examiner is unable to flex the patient’s kneepast 90 degrees because of a pathological condition in the hip, the test may beperformed by passive extension of the hip while the knee is flexed as much as possible.The flexed knee position should be maintained for 45 to 60 seconds. Unilateralneurological pain in the lumbar area, buttock, and/or posterior thigh may indicate an L2or L3 nerve root lesion. Pain in the anterior thigh indicates tight quadriceps muscles orstretching of the femoral nerve.Hoffmann’s sign – The examiner holds the patient’s middle finger and briskly flicks thedistal phalanx. A positive test is noted if the interphalangeal joint of the thumb of thesame hand flexes. 2019 eviCore healthcare. All Rights Reserved.Page 8 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comSpine ImagingSlump test – The patient is seated on the edge of the examination table with the legssupported, the hips in neutral position, and the hands behind the back. The examinationis performed in sequential steps. First, the patient is asked to “slump” the back intothoracic and lumbar flexion. The examiner maintains the patient’s chin in neutralposition to prevent neck and head flexion. The examiner then uses one arm to applyoverpressure across the shoulders to maintain flexion of the thoracic and lumbar spines.While this position is held, the patient is asked to actively flex the cervical spine andhead as far as possible (i.e., chin to chest). The examiner then applies overpressure tomaintain flexion of all three parts of the spine (cervical, thoracic, and lumbar) using thehand of the same arm to maintain overpressure in the cervical spine. With the otherhand, the examiner then holds the patient’s foot in maximum dorsiflexion. While theexaminer holds these positions, the patient is asked to actively straighten the knee asmuch as possible. The test is repeated with the other leg and then with both legs at thesame time. If the patient is unable to fully extend the knee because of pain, theexaminer releases the overpressure to the cervical spine and the patient activelyextends the neck. If the knee extends further, the symptoms decrease with neckextension, or the positioning of the patient increases the patient’s symptoms, then thetest is considered positive.

Imaging GuidelinesV1.0.2019Babinski’s sign – The examiner runs a sharp instrument along the plantar surface ofthe foot from the calcaneus along the lateral border to the forefoot. A positive testoccurs with extension of the great toe with flexion and splaying of the other toes. Anegative test occurs with no movement of the toes at all or uniform bunching up of thetoes.Chaddock sign – The examiner strokes the lateral malleolus. A positive test occurswith extension of the great toe.SP-1.2: Red Flag IndicationsRed Flag Indications are intended to represent the potential for life or limb threateningconditions. Red Flag Indications are clinical situations in which localized spine pain andassociated neurological features are likely to reflect serious underlying spinal and/ornon-spinal disease and warrant exception to the requirement for documented failure ofsix weeks of provider-directed treatment. Advanced diagnostic imaging of thesymptomatic level is appropriate and/or work-up for a non-spinal source of spine painfor Red Flag Indications. Red Flag Indications include: Motor Weakness Aortic Aneurysm or Dissection Cancer Cauda Equina Syndrome Fracture Infection Severe Radicular PainMotor Weakness ( See: Grading of Manual Muscle Testing and ReflexTesting in SP-1.1: General Considerations )Clinical presentation including one or more of thefollowing: Motor weakness of grade 3/5 or less of specifiedmuscle(s); New onset foot drop; Acute bilateral lower extremity weakness; Progressive objective motor /sensory/deep tendonreflex deficits on clinical re-evaluation.Advanced DiagnosticImagingMRI of the relevant spinal levelwithout contrast or MRI of therelevant spinal level without andwith contrast 2019 eviCore healthcare. All Rights Reserved.Page 9 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comSpine ImagingHistory, Symptoms or Physical Exam Findings(Initial clinical evaluation required within the last60 days)

Aortic Aneurysm or DissectionHistory, Symptoms or Physical Exam Findings(Initial clinical evaluation required within thelast 60 days) New onset of back and/or abdominal pain in anindividual with a known AAA; or Acute dissection is suspected.CancerHistory, Symptoms or Physical Exam Findings(Initial clinical evaluation required within thelast 60 days)Clinical presentation including one or more of thefollowing: There is clinical suspicion of spinal malignancyAND one or more of the following: Night pain Uncontrolled or unintended weight loss Pain unrelieved by change in position Age greater than 70 years Severe and worsening spinal pain despite areasonable (generally after 1 week) trial ofprovider-directed treatment with reevaluation; or Known metastatic malignancies; or acute spinalcord compression from primary or metastaticspinal neoplastic disease is suspected by historyand physical examination.Cauda Equina SyndromeHistory, Symptoms or Physical Exam Findings(Initial clinical evaluation required within thelast 60 days)Clinical presentation including one or more of thefollowing: Acute onset of bilateral sciatica; Perineal sensory loss (“saddle anesthesia”); Decreased anal sphincter tone; Bowel/bladder incontinence; Acute urinary retention.V1.0.2019Advanced DiagnosticImagingSee: PVD-6: Aortic Disorders,Renal Vascular Disorders andVisceral Artery Aneurysmsand/or CH-30: Thoracic AortaAdvanced DiagnosticImagingMRI of the relevant spinal levelwithout contrast or MRI of therelevant spinal level without andwith contrast; CT without contrastof the relevant spinal level if MRIcontraindicated.See also: ONC-31.5: Bone(including Vertebral)Metastases and ONC-31.6:Spinal Cord Compression in theOncology Imaging Guidelines.Advanced DiagnosticImagingMRI Lumbar Spine withoutcontrast (CPT 72148) or MRILumbar Spine without and withcontrast (CPT 72158)Fracture 2019 eviCore healthcare. All Rights Reserved.Page 10 of 63400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924www.eviCore.comSpine ImagingImaging Guidelines

Imaging GuidelinesHistory, Symptoms or Physical Exam Findings(Initial clinical evaluation required within thelast 60 days)There is clinical suspicion of spinal fracture related toone or more of the following: Long term use of systemic glucocorticoids; History of prior low energy fractures; History of low bone mineral density; Age 65 years; Recent significant trauma at any age; High speed vehicular accident; Ejection from a motor vehicle; Fall from elevation 3 feet/5 stairs; Head trauma and/or maxillofacial trauma Patients with ankylosing spondylitis are at highrisk of cervical spine fractures even with minordirect/indirect trauma to

Guidelines. eviCore Code Management for BCBS AL 3 Procedure Codes Associated with Spine Imaging 4 SP-1: General Guidelines 5 . ankle dorsi/plantar Guidelines V1.0. 2019 . Spine Imaging. flexion, wrist dorsi/palmar flexion) and gradation of muscle testing should be documented as follows: Grading of Manual Muscle Testing .

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