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CLINICAL GUIDELINES Spine Imaging Policy Version 2.0.2019 Effective August 1, 2019

eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual’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 data are 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.

Spine Imaging Guidelines Procedure Codes Associated with Spine Imaging 3 SP-1: General Guidelines 4 SP-2: Imaging Techniques 13 SP-3: Neck (Cervical Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma 21 SP-4: Upper Back (Thoracic Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma 25 SP-5: Low Back (Lumbar Spine) Pain/Coccydynia without Neurological Features 27 SP-6: Lower Extremity Pain with Neurological Features (Radiculopathy, Radiculitis, or Plexopathy and Neuropathy) With or Without Low Back (Lumbar Spine) Pain 31 SP-7: Myelopathy 35 SP-8: Lumbar Spine Spondylolysis/Spondylolisthesis 38 SP-9: Lumbar Spinal Stenosis 41 SP-10: Sacro-Iliac (SI) Joint Pain, Inflammatory Spondylitis/Sacroiliitis and Fibromyalgia 43 SP-11: Pathological Spinal Compression Fractures 46 SP-12: Spinal Pain in Cancer Patients 48 SP-13: Spinal Canal/Cord Disorders (e.g. Syringomyelia) 49 SP-14: Spinal Deformities (e.g. Scoliosis/Kyphosis) 51 SP-15: Post-Operative Spinal Disorders 54 SP-16: Other Imaging Studies and Procedures Related to the Spine Imaging Guidelines 57 SP-17: Nuclear Medicine 61

Procedure Codes Associated with Spine Imaging MRI/MRA CPT® Cervical MRI without contrast 72141 Cervical MRI with contrast 72142 Cervical MRI without and with contrast 72156 Thoracic MRI without contrast 72146 Thoracic MRI with contrast 72147 Thoracic MRI without and with contrast 72157 Lumbar MRI without contrast 72148 Lumbar MRI with contrast 72149 Lumbar MRI without and with contrast 72158 Spinal Canal MRA 72159 MRI Pelvis without contrast 72195 MRI Pelvis with contrast 72196 MRI Pelvis without and with contrast 72197 CT CPT® Cervical CT without contrast 72125 Cervical CT with contrast (Post-Myelography CT) 72126 Cervical CT without and with contrast 72127 Thoracic CT without contrast 72128 Thoracic CT with contrast (Post-Myelography CT) 72129 Thoracic CT without and with contrast 72130 Lumbar CT without contrast (Post-Discography CT) 72131 Lumbar CT with contrast (Post-Myelography CT) 72132 Lumbar CT without and with contrast 72133 CT Pelvis without contrast 72192 CT Pelvis with contrast 72193 CT Pelvis without and with contrast 72194 Ultrasound CPT® Spinal canal ultrasound 76800 Nuclear Medicine CPT® Bone Marrow Imaging, Limited 78102 Bone Marrow Imaging, Multiple 78103 Bone Marrow Imaging, Whole Body 78104 Bone or Joint Imaging, Limited 78300 Bone or Joint Imaging, Multiple 78305 Bone Scan, Whole Body 78306 Bone Scan, 3 Phase Study 78315 Bone Joint Imaging Tomo Test SPECT 78320 Radiopharmaceutical Localization of Abscess, Limited Area 78805

Radiopharmaceutical Localization of Abscess, Whole Body 78806 maging Radiopharmaceutical Localization of Abscess, tomographic (SPECT) 78807 Spine I

SP-1: General Guidelines SP-1.1: General Considerations 5 SP-1.2: Red Flag Indications 8 SP-1.3: Definitions 11

SP-1.1: General Considerations  Before advanced diagnostic imaging can be considered, there must be an initial face-to-face clinical evaluation as well as a clinical re-evaluation after a trial of failed conservative therapy; the clinical re-evaluation may consist of a face-to-face evaluation or other meaningful contact with the provider’s office such as email, web or telephone communications.  A face-to-face clinical evaluation is required to have been performed within the last 60 days before advanced imaging is considered. This may have been either the initial clinical evaluation or a clinical re-evaluation.  The initial clinical evaluation should include a relevant history and physical examination (including a detailed neurological examination), appropriate laboratory studies, non-advanced imaging modalities, results of manual motor testing, the specific dermatomal distribution of altered sensation, reflex examination, and nerve root tension signs (e.g., straight leg raise test, slump test, femoral nerve tension test). The initial clinical evaluation must be face-to-face; other forms of meaningful contact (telephone call, electronic mail or messaging) are not acceptable as an initial evaluation.  For those spinal conditions/disorders for which the Spine Imaging Guidelines require a plain x-ray of the spine prior to consideration of an advanced imaging study, the plain x-ray must be performed after the current episode of symptoms started or changed (see SP-2.1: Anatomic Guidelines).  Clinical re-evaluation is required prior to consideration of advanced diagnostic imaging to document failure of significant clinical improvement following a recent (within 3 months) six week trial of provider-directed treatment. Clinical re-evaluation can include documentation of a face-to-face encounter or documentation of other meaningful 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 analgesic medications, oral or injectable corticosteroids, a provider-directed home exercise/stretching program, cross-training, avoidance of aggravating activities, physical/occupational therapy, spinal manipulation, interventional pain procedures and other pain management techniques.  Any bowel/bladder abnormalities or emergent or urgent indications should be

documented at the time of the initial clinical evaluation and clinical re-evaluation.  Altered sensation to pressure, pain, and temperature should be documented by the specific anatomic distribution (e.g., dermatomal, stocking/glove or mixed distribution). Spine Imaging

 Motor deficits (weakness) should be defined by the specific myotomal distribution (e.g., weakness of toe flexion/extension, knee flexion/extension, ankle dorsi/plantar flexion, wrist dorsi/palmar flexion) and gradation of muscle testing should be documented as follows: Grading of Manual Muscle Testing 0 No evidence of muscle function 1 Muscle contraction but no or very limited joint motion 2 Movement possible with gravity eliminated 3 Movement possible against gravity 4 Movement possible against gravity with some resistance 5 Movement possible against gravity with full or normal resistance  Pathological reflexes (e.g. Hoffmann’s, Babinski, and Chaddock sign) should be reported as positive or negative.  Asymmetric reflexes and reflex examination should be documented as follows: Grading of Reflex Testing 0 No response 1+ A slight but definitely present response 2+ A brisk response 3+ A very brisk response without clonus 4+ A tap elicits a repeating reflex (clonus)

 Advanced diagnostic imaging is often urgently indicated and may be necessary if serious underlying spinal and/or non-spinal disease is suggested by the presence of certain 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 advanced diagnostic imaging, especially for patients following spinal surgery.  The need for repeat advanced diagnostic imaging should be carefully considered and 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 be documented as required for preoperative surgical planning. These studies may be helpful in the evaluation of complex failed spinal fusion cases or needed for preoperative surgical planning when the determination of both soft tissue and bony anatomy is required.  Serial advanced imaging, whether CT or MRI, for surveillance of healing or recovery from spinal disease is not supported by the currently available scientific evidence-

based medicine for the majority of spinal disorders.  Advanced imaging is generally unnecessary for resolved or improving spinal pain and/or radiculopathy.  For patients experiencing chronic spine pain, advanced diagnostic imaging has not been shown to be of value in patients with stable, longstanding spinal pain without neurological features or without clinically significant or relevant changes in symptoms or physical examination findings. Spine Imaging

______© 2019 eviCore healthcare. All Rights Reserved. Page 7 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com same same distal phalanx. A positive test is noted if the interphalangeal joint of the thumb of the – sign Hoffmann’s stretchingof the femoralnerve. or L3 nerve root lesion. Pain in the anterior thigh indicates tight quadriceps muscles or neurological pain in the lumbar area, buttock, and/or posterior thigh may indicate an L2 The flexedknee position should bemaintainedseconds.45 to for 60 Unilateral performed by passive extension of the hip while the knee is flexed as much as possible. past 90 degrees because of a pathological condition in the hip, the test may be that the patient’s hip is not rotated. If the examiner is unable to flex the patient’s knee patient’s heel rests against the buttock. At the same lies prone while the examiner passively flexes the knee as far as possible so that the Femoral nerve tension test test is considered positive. extension, or the positioning of the patient increases the patient’s symptoms, then the extends the neck. If the knee extends further, the symptoms decrease with neck examiner releases the overpressure to the cervical spine and the patient actively same time. If the patient is unable to fully extend the knee because of pain, the much as possible. The test is repeated with the other leg and then with both legs at the examiner holds these positions, the patient is asked to actively straighten the knee as hand, the examiner then holds the patient’s foot in maximum dorsiflexion. theWhile hand of the same arm to maintain overpressure in the cervical spine. theWith other maintain flexion of all three parts of the spine (cervical, thoracic, and lumbar) using the head as far as possible (i.e., chin to chest). The examiner then applies overpressure t While this position is held, the patient is asked to actively flex the cervical spine and overpressure across the shoulders to maintain flexion of the thoracic and lumbar spines. positionto prevent neck andhead flexion.examiner The thenuses onearm to apply thoracic and lumbar flexion. The examiner maintains the patient’s chin in neutral is performed in sequential steps. First, the patient is asked to “slump” the back into supported, the hips in neutral position, and the hands behind the back. The examination – test Slump considered to be provocative tests for neurological tissue. foot, or both actions may bedone simultaneously. Both of these to flex the neck so the chin is on the chest, or the examiner may dorsiflex the patient’s (extends it) slightly until the patient feels no pain or tightness. The patient is then asked cause pain in both areas. The examiner then slowly andcarefully drops back the leg herniation or pathology causing pressure between the two extremes are more likely to that the pathology causing the pressure on neurological tissues is more lateral. Disc pathology causing the pain is more central. If pain is primarily in the leg, it isre mo likely back of the leg. If the pain is primarily back pain, it is more likely adisc herniation or the examiner flex supine position, the hip medially rotated and adducted, and the knee extended, the Straight leg raise test P 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 ractice Notes hand flexes. es the hip until the patient complains of pain or tightness in the back or The patient is seated on the edge of the examination table with the legs

The examiner holds the patient’s middle finger and briskly flicks the

(also known as the Lasegue’s test)

(also known as the prone knee bending test) –

time, the examiner should ensure

– – With theWith patient in the maneuvers are www.eviCore.com

The patient Page 8of62 V2.0.2019 V2.0.2019 o

Spine Imaging AorticAneurysm or Dissection Testing Weakness Motor  for Red Flag Indications. symptomatic level is appropriate and/or work six providerweeks of non- associated neurological features are likely to reflect serious underlying spinal conditions. Red Flag Indications are intended to represent the potential for life or limb threatening :SP-1.2 with extension of the great toe. sign – Chaddock toes. negative test occurs with no movement of the toes at all or uniform bunching up of the occurs with extension of the great toe with flexion andsplaying the of othertoes. A the foot from the calcaneus along the lateral border to the forefoot. A positive test sign – Babinski’s 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 Clinical presentationincludingoneormeoftheollowing: (Initial clinical evaluation clinical (Initial required the within 60last days) evaluation clinical (Initial required the within 60last days)        Red Flag Indications include:  Acutedissectioniss  Newonsetofbackand/orabdominalpaininan  Progressiveobjectivemotor/sensory/deep  Acutebilaterallowerex  Newonsetfootdrop;  Motorweaknessofgrade3/5orlessspecified spinaldisease andwarrant exception requirement to the documented for failureof

H H Severe Radicular Pain Infection Fracture Cauda Equina Cancer Aortic Aneurysm or Dissection M ; or individual withaknownAAA reflex deficitsonclinicalre-ev muscle(s); istory, Symptoms or Symptoms istory, Findings Exam Physical or Symptoms istory, Findings Exam Physical otor Weakness

Red Flag Indications Flag Red in

Red Flag Indications are clinical situations in which localized spine pain and

SP- 1.1 The examiner strokes the lateral malleolus. A positive test occurs The examiner runs asharp instrument along the plantar surface of : : - ( Syndrome directed treatment. Advanced diagnostic imaging of the General Considerations General See: See:

. uspected tremity weakness; Grading of Manual Muscle Testing and Reflex and Testing Muscle Manual of Grading

aluation.

- up for a non a- up for tendon ) )

spinal source of spine pain or CH-29: Artery Aneurysmsand/ andVisceralDisorders Renal Vascular Disorders, See: without andwithcontrast of therelevantspinallevel level withoutcontrastorMRI MRI oftherelevantspinal Advanced Diagnostic Advanced Diagnostic Advanced Diagnostic PVD - Imaging Imaging Thoracic Aorta 6: Aortic www.eviCore.com

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Spine Imaging Fracture Cauda Cancer 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 more ofmore the following: is There clinical of suspicion spinal related to oneorfracture one including orClinical more presentation of the following: Clinical presentationincludingoneormeofthefollowing: (Initial clinical evaluation clinical (Initial required the within 60last days) evaluation clinical (Initial required the within 60last days) (Initial clinical evaluation clinical (Initial required the within 60last days)  Patientswithankylosingspondylitisareathighrisk     Highspeedvehicularaccident;  Recents   Historyoflowbonemineraldensity;  Historyofpriorlowenergyfractures;  Longtermuseofsystemicglucocorticoids;  Acuteurinaryretention.  Bowel/bladderi  Decreasedan  Perineals  Acuteonsetofbilateralsciatica;  Kn  Thereisclinicalsuspicionofpinalmalignancy Headtraumaand/ormaxillofacialtrauma Fall from Age H H H indirect trauma of result inquadriparesis/quadriplegia. Ejection fromamotorvehicle;  S  A A physical examination. neoplastic diseaseiss c  P  Uncontrolledorunintendedweightloss  Nightpain

ry, or Symptoms isto Findings Exam Physical istory, Symptoms or Symptoms istory, Ph istory, Symptoms or Symptoms istory, Fin Exam Physical ord compressionfrompr Equina Syndrome Equina ND oneormoreofthefollowing: cervical s orac own metastaticmalignancies; provider-d reasonable (generallyafter ≥ 65years; evere andworseningspinalpaindespitea ge greaterthan70years ain unrelievedbychangeinposition

ignificant traumaatnyage; elevation ensory loss direct/ pine fracturesevenwithminor irected treatmentwithre-e tone; al sphincter

ncontinence; spinewhichcan to thecervical 3 feet/5 ≥ 3 (“saddleanesthesia”); uspected byhistoryand uspected imary ormetastaticspinal ysical Findings Exam

stairs; 1week)trialof ute spinal valuation; or dings

and with (CPT contrast SpineMRI Lumbar without Guidelines. in theOncologyImaging Compression ONC-3 and Metastases (including Vertebral) See also:ONC-3 c relevant spinallevelifMRI CT withoutcontrastofthe without andwithcontrast; of therelevantspinallevel level withoutcontrastorMRI MRI oftherelevantspinal 72158) (CPT contrast SpineMRI Lumbar without without contrast without level spinal relevant the of or contrast level without MRI of the spinal relevant ontraindicated. Advanced Diagnostic Advanced Diagnostic Advanced Diagnostic Advanced Diagnostic Advanced Diagnostic Advanced Diagnostic 1.6: SpinalCord

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V2.0.2019 V2.0.2019 Bone Bone ® or or

CT CT

Spine Imaging Severe Radicular Pain Radicular Severe Infection 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 mor abscess epidural infection, is aThere clinical of suspicion spinal infection (Initial clinical evaluation clinical (Initial required the within 60last days) (Initial clinical evaluation required within the  Organtransplantrecipienttakinganti-re  Longtermuseofsystemicglucocorticoids;  Immunocompromisedstates; (UTIs,pyelonephritis,  Recentbacterialinfection  Treatmentpl  Severityofpainunresponsivetoa  Documentedsignificantfunctionallossat spinal  Severeradicularpaininaspecified  Immunosuppressanttherapy.  Chronicd  HIV/AIDS;  Diabetesmellitus;  Historyof  Fever; e of the following: A H  pneumonia);  Int  Tra following: directed treatment;and m work orathome;and the VAS);and nerve rootdistribution(minimum9/10on m ll of the following must be present present must be following of the ll istory, Symptoistory,

edication; inimum ofseven(7)day A p (ILESI) atthecervicalorhoracic (TFESI) atanylevel(s);or erlaminar epiduralsteroidinjection lan f nsforaminal epiduralsteroidinjection IVdruguse; ialysis; or l an includes ast 60 days) urgent/emergentspinalurgery.

ms orms Findings Exam Physical or spinal and osteomyelitis) oneor

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ofprovider- levels;or (e.g., space disc jection

without contrast contrast without MRI with contrast contrast with

Advanced Diagnostic Imaging Diagnostic Advanced of the spinal relevant level

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Spine Imaging 7. 6. 5. 4. 3. 2. 1. R    :SP-1.3 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 eferences Magee DJ. Orthopedic Physical Assessment, 4th edition. Saunders. Philadelphia. 2002. Philadelphia. Saunders. edition. 4th Assessment, Physical Orthopedic DJ. Magee 1976. Riv Saddle Upper Hall. Prentice Extremities. and Spine the of Examination S. Physical Hoppenfeld - outcome and treatment back Low al. et MG, AM, Gillan Grant FJ, Gilbert Res Pediatr Curr osteomyelitis. actue by affected children of follow the in imaging resonance magnetic of Utility al. et. M, Napolitano G, V, Franchino Fabiano - 42:504 2017; Journal Spine sciatica. and/or pain back low with patients inyear 1 to up of period a over change JAMA pain? back low about us tell examination physical and history the can DL. What Kent J, Rainville RA, Deyo 145. 141- 147: 1987; Med. Intern Arch use. roentgenography Reducing M. Rosenthal AK, Dieh RA, Deyo doi:10.1148/radiol.2312030886. follow A, Vleggeert Barzouhi objectiveneurological findings. R and/or injury to the nerve root. course of aspinal nerve root, typically resulting from compression, inflammat Radicular pain     an involved named spinal root(s) and paraesthesia(s) reported by the individual in a specified dermatomal distribution of impaired, age- resulting in significant functional limitations (i.e., diminished quality of life and Radiculopathy

adiculitis   E with nerve root compression of the involved named spinal nerve root(s). D nerve roo t(s). distribution concordant with nerve root compression of the involved named spinal on a detailed neurologic examination (within the prior 3 months) in the sensory A root( concordant with nerve root compression of the involved named spinal nerve demonstrated on detailed neurologic examination (within the prior 3 months), L

oss of strength of specific named muscle(s) specific of or myotomal distribution(s) strength of oss or - ither of the following: ltered sensation to light touch, pressure, pin prick or temperature demonstrated iminished, absent or asymmetric reflex(es) within the prior 3 months concordant up assessment of sciatica. N Engl Med sciatica. J of assessment up Definitions months). of the involved named spinal nerve root(s). (Performed within the prior 12 Electrodiagnostic studies (EMG/NCV’s) diagnostic of nerve root (Performed within the prior 12 months named spinal nerve root(s) or foraminal stenosis at the concordant level(s) study (MRI or CT) of the spine demonstrating compression of the involved A concordant radiologist’s interpretation of an advanced diagnostic imaging s).

. 1992; 268(6): 760- 268(6): 1992; .

512. doi:10.1097/BRS.00 512. is defined, for the purpose of this policy, as radicular pain without appropriate activities of daily living), or dysaesthesia(s) , the for purpose of this policy, is defined as the presence of pain

is pain which radiates to the upper or lower extremity along the

- Lankamp C, Lycklama a Nijehold G, et al. Magnetic resonance imaging in imaging resonance Magnetic al. et G, aNijehold Lycklama C, Lankamp

multicenter randomized trial. Radiology. trial. randomized multicenter

765. Panagopoulos J, Hush J, Steffens D, et al. Do MRI findings MRI Do al. et D, Steffens J, Hush J, Panagopoulos 00000000001790. ONE or ONE . 2013; 368;11: 999- 368;11: 2013; .

pain: influence of early MR imaging or CT on CT or imaging MR early of influence pain: ).

MORE . 2017; 21(2): 354- 21(2): 2017; .

of theof following: - 231:343 2004; 1007. 351. 358. www.eviCore.com

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Spine Imaging 11. 8. 10. 13. 12. 9. 14. 15. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 Criteria Panel Expert al. et. J, Burns DF, Broderick ND, Patel - 2012;94 Br. Surg Joint Bone J compression. root nerve lumbosacral and lumbar by caused weakness of management Cole AA. The SWJ, Lee H, Sharma 169- 100(1): Jan; 2016 Am. North Clin Med pain. back low chronic and Acute MA, Knaub E, Emanski N, Patrick https://acsearch.acr.org/docs/69483/Narrative/ 2017. 20, on October Accessed 2015. -1- doi:10.1007/978 2014. Imaging. Diagnostic to Guide Clinician’s WR. Reinus . 12;347:f7432 Dec 2013 BMJ. pain. back for flags Red R. Buchbinder M, Underwood . Med J Engl N Trauma. with Patients in Criteria C Canadian al. The et RD, McKnight CM, Clement IG, Stiell - 25:2788 2016; Spine Eur J. review. a guidelines: pain back low current in presented flags Red al. et N, Popal A, Downie A, Verhagen JAMA Visconti AJ, Biddle J, Solomon M. Follow M. Solomon J, Biddle AJ, Visconti . 10.1001/jamainternmed.2013.12742 doi: 184. 174(2): 2014; . ® : Low Back Pain. American College of Radiology (ACR); Radiology of College American Pain. Back Low : 81. 2802. - up imaging for vertebral osteomyelitis a teachable moment. a teachable osteomyelitis vertebral for imaging up - 2003;349:2510 on Neurologic Imaging. ACR Appropriateness ACR Imaging. Neurologic on - B:1442 - Spine Rule versus the NEXUS Low NEXUS the versus Rule Spine 8. 7.

Date of Origin: 1996. Review: Last 1996. Origin: of Date - 4614 www.eviCore.com

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Spine Imaging Imaging Guidelines V2.0.2019

SP-2: Imaging Techniques SP-2.1: Anatomic Guidelines 14 SP-2.2: MRI of the Spine 14 SP-2.3: CT of the Spine 15 SP-2.4: CT/Myelography 16 SP-2.5: Lumbar Provocative Discography CT 16 SP-2.6: Ultrasound of the Spinal Canal 17 SP-2.7: Limitations of Spinal Imaging in Degenerative Disorders 18 SP-2.8: Miscellaneous Spinal Lesions 18 SP-2.9: MRA Spinal Canal 19 SP-2.10: Spine PET 19 SP-2.11: Cone-beam CT 20

______© 2019 eviCore healthcare. All Rights Reserved. Page 14 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com    :SP-2.2    :SP-2.1 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019  including:    S disorders, frac without contrast. Contrast is generally not indicated for most disc and nerve root contrast. A “with contrast” study alone is appropriate only to complete astudy begun S See        P tethered cord ). spinal cord unless there is known or suspected low lying conus Therefore, lumbar spine imaging is not needed when the goal is to image only the the end of the spinal cord or conus CT or MRI of the cervical and thoracic spine will image the entire spinal cord s     advanced diagnostic imaging studies: Anatomic regions of the spine/pelvis that are included in the following MRI andCT pine MRI indications include pine MRI is performed either without contrast, with contrast x lain

Se flag” indications other causes of myelitis, syringomyelia, cauda Suspicion, diagnosis of or surveillance of spinal infections, multiple sclerosis or disease. Suspicion orfor surveillance of known spine/spinal canal/spinal cord neoplastic spinal cord spinal conditions including evaluation of congenital anomalies of the spine and E See Fibromyalgia and See Dysraphism Spinal See See Trauma Spine) See See See Pelvis: includes hips, sacroiliac joints, sacrum, coccyx Lumbar spine: from T12 through mid- Thoracic spine: from C7 through L1 C Procedure CodesAssociated with Spine Imaging valuation of disc disease, spinal cord and nerve root disorders and most other ervicalspine: from e MRI of the Spine of MRI Anatomic Guidelines Anatomic - ray should be the initial evaluation for certain suspected spine conditions, SP- SP- SP- SP- SP- SP- SP- SP-8: 11

15 10 14 Features Coccydynia Neurological 5.2: without 3.2 : 10.2 : : tures and degenerative disease. : : : : Lumbar Lumbar

: : Pathological Pathological Post Sacro Spinal Deformities (e.g. Neck ( Inflammatory Inflammatory , and SP . See See -O -

Ili perative Cervical

Spine Spine

the skull base/foramen magnum through T1 ac (SI) Joint Pain, Inflammatory Spondylitis/Sacroiliitis SP

- - 6.2 1.2 : Spinal C Spondylolysis/Spondylolisthesis : : : :

S Spondylitis

Spine) Trauma Low Back ( Red Flag Indications Red pinal pinal

medullarisusually inends at L1 adults. ompression ompression D sacrum isorders Scoliosis/Kyphosis L umbar , SP- equina syndrome or other “red

4.2 ractures Spine) . : : Upper Back (

or Trauma

)

medullaris (e.g. and without andwith PEDSP -4: www.eviCore.com

Thoracic Page 15of62 V2.0.2019 V2.0.2019 ince

Spine Imaging   SP-2.  Position 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019         S See this study. As such, it should beconsidered experimental or investigational. Currently, there is inadequate scientific evidence to support the medical necessity of P   pine CT indications include: ositional MRI is also referred to as dynamic, weight

3: Congenital, developmentalor acquired spinal deformity no concordant clinical signs or symptoms). Surgery Spine longitudinal To evaluate calcified lesions, (e.g., osteophytes, ossification of the posterior Spine Lumbar negative and/or MRI is equivocal, indeterminate or non- Deformities routine post To assess spinal fusions when pseudoarthrosis is suspected (not to be used for Surgery to Spine Prior could influence the outcome of a potential surgical procedure Preoperativeevaluation to define abnormal orvariant and In conjunction with myelography or discography ( Spinal neoplasticdisease spinal instability andspinal cord/spinal nerve compression. Any spinal trauma/fractures, especially spinal trauma/fractures that could result in not determined by the manufacturer as MRI compatible). electronically, magnetically or mechanically activated implanted devices that are I fluid (CSF) leak. examination is suspicious for hematoma, post laminectomy, discectomy, spinal decompression, when history and physical Spinal imaging for patients having undergone recent spinal surgerye.g., influence the outcome of a potential surgical procedure. See Preoperative evaluation to define abnormal or variant spinal anatomy that could ndividuals who cannot have MRI (with implanted ferromagnetic materials or Procedure CodesAssociated with Spine Imaging CT of the CT of the Spine al MRI: al SP- 2.5 :

- ligament [OPLL]). operative assessment where x Lumbar Provocative DiscographyCT

[ e.g. e.g.

. . Spondylolysis/Spondylolisthesis

Scoliosis/Kyphosis

) ) – – primary or metastatic.

] ) .Spondylolysiswhen routi

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bearing or kinetic MRI. ). ).

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spinal anatomythat : : SP- SP- CT/Myelography (s ee ee 14 16.1: Prior to Prior 16.1: www.eviCore.com ne x ne SP :

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Spine Imaging   Practice Notes  :SP-2.5    :SP-2.4 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019    T for spinal fusion in patients with non- pain. This diagnostic study, when reported as positive, is often used as an indication rule Provocative Discography/CT is acontroversial procedure purported to diagnose (or    following apply: considered medically necessary following anapproved discography and ALL of the anyother discography eviCore authorizes only the post     C quality MRI has been obtained. C See he following uses of discography are considered controversial:

T/Myelography indications include: T/Myelography is generally unnecessary as aninitial study when a diagnostic eviCore authorizes only the post CPT determined clinically or otherwise. To identify which two of herniated discs seen onMRI is symptomatic when not T codes. approved apost When performed as a post A CT lumbar spine without contrast (CPT A   and CPT contraindicated or MRI results are equivocal, indeterminate or non- Evaluation after previous spinal surgerywhen anMRI without and with contrast is SP- a previous MRI is insufficient, equivocal, indeterminate or non- Preoperative planning for spine surgery, (e.g., multilevel spinal stenosis or when ( contraindicated is MRI an When evaluate the significance of multiple spinal abnormalities. T - out) a discogenic “pain generator.” i.e., the source of non-

Procedure CodesAssociated with Spine Imaging o identify asymptomatic pseudoarthrosis in a failed spinal fusion. o clarify equivocal, indeterminate or non- post Lumbar Provocative Discography CT Discography Provocative Lumbar CT/Myelography procedure codes. requ Providers are urged to obtain written instructions and prior authorization procedurecodes andrequirements mayvarybyhealth plan payer. Providers may berequired to obtain prior authorization for myelogram 16.1: Prior to Spine Surgery ® 72265CPT or -discogra

irements directly from each health plan payer for myelogram ® e 72132) and not any other myelogram viCore will issue authorization thefor post - discography CT is requested and the discography has already been phy -

related procedurecodes. A post- CT is coded as without contrast. -discogra ®

62284).

phy lumbar discography CT procedure codes and not - myelogram CT (i.e., CPT (i.e., CT myelogram

specific axial back pain. ee see

CT.

SP- ® 2.2 diagnostic MRI findings or to further 72131) is appropriate if verified to be : : MRI of the Spine MRI of the - related procedure codes

lumbar discography CT is - discographyCT procedure

® specific axial spinal 72126, CPT diagnostic). ).

www.eviCore.com diagnostic.

- related Page 17of62

V2.0.2019 V2.0.2019 ®

- 72129, (i.e., related

See See

Spine Imaging      (CPT ultrasound canal spinal for Indications    :SP-2.6 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 tissue conditions surrounding the adult spine other than superficialfor masses radiculopathy, facet inflammation, nerve root inflammation, disc herniation, and soft C trauma. E Dysraphism Spinal E suspected or known tethered cord (see PEDSP-5: W puncture. including the assessment of CSF in the spinal canal and for image- incomplete ossification of the vertebral segments surrounding the spinal cord, T (CPT canal ultrasound (ultrasonic guidance). Int C multiple times imagingfor of different areas of the spinal canal. C intraoperatively. (canal and contents) most often performed in newborns, infants, young children and Spinal canal ultrasound (CPT    his study is generally limited to infants, newborns and young children because of valuation of spinal cord tumors, vascular malformations and cases of birth- valuation of suspected occult and non-

ontraindicated usethe for in adult spine for the assessment of spinal pain, PT PT hen ossification of the vertebral segments is incomplete for evaluation of Discography the of cervical and/or thoracic spine. To confirm the presumptive diagnosis of “internal disc disruption”. MRIandtoruleon out pain from anadjacent disclevel. To confirm the discogenic nature of pain in a patient with an abnormal disc seen ® ® ® 76998, rather than CPT 76800 descr Ultrasound of the Spinal Canal the Spinal of Ultrasound 76998) would not require prior authorization by eviCore.

ibes evaluation of the entire spine and should not bereported ). ® ® 76800) describes the evaluation of the spinal cord 76800, should be used to report intraoperative spinal occult spinal dysraphism (see PEDSP-4: raoperativespinaluse of ultrasound

). Cord Tethered

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guided lumbar

www.eviCore.com

Page 18of62 V2.0.2019 V2.0.2019 related .

Spine Imaging    cysts: Tarlov   hemangiomas: body Vertebral :SP-2.8     :SP-2.7    400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 CT/Myelography (CPT with aMRI without and with contrast study (CPT studies. Further evaluation of aknown or suspected Tarlov cyst can be performed U symptoms but they can result in erosion of the adjacent bone. C spinesacrum. and T I findings on plain x V are either asymptomatic or present with non- degenerative findings identified on x P or substantive and may even lead to inappropriate treatment. diagnostic imaging results are infrequently clinically concordant, significant, material I as the spine ages. herniated discs,are often non - I infrequently identifies the source of the spinal pain (pain generator). Non I associated neurologic symptoms or signs on physical examination. spinal advanced diagnostic imaging is not usually required, unless there are hemangioma is established without neurological features. N without contrast of the spinal area is indicated to help clarify the diagnosis. O MRI without and with contrast is indicated. without neurological signs or symptoms on physical exam, MRI without contrast or f the appearance of a vertebral body hemangioma is typical on plain x n individuals with poorly defined clinical presentations, “abnormal” spinal advanced ncidental findings on MRI andCT, including bulging, protruding, extruding or f the appearance of a vertebral body hemangioma is atypical on plain x arlov cysts are most often cystic dilatations of nerve root sleeves in the lumbar ertebral body hemangiomas are common and are generally benign and incidental erforming advanced spinal imaging based only onthe presence of spinal sually Tarlov cysts benign, are incidental findings onadvanced diagnostic imaging ontroversy exists as to whether Tarlov cysts can result in neurologic signs and o follow ccasionally, MRI may be equivocal, indeterminate or non- - specific axial spinal pain is ubiquitous. Advanced diagnostic imaging Miscellaneous Spinal Lesions Spinal Miscellaneous enerative Deg Disorders in Imaging Spinal of Limitations - up imaging is necessary once the diagnosis of a vertebral body - rays and advanced diagnostic imaging studies. ® 72132). concordant, asymptomatic and increase in incidence - rays is generally not indicated in patients who

specific axial spinal pain. ® 72158) or with Lumbar diagnostic andCT www.eviCore.com - ray, further ray,

- ray, (with or (with ray, Page 19of62 V2.0.2019 V2.0.2019

Spine Imaging    SP-2.10    may include: Indications    :SP-2.9  lesions: spinal Other 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 70551, 70552,and70553 andshould not becodedreportedor separately. forwarded to Medical Director Review. S S assessment of spinal disorders, other than for neoplastic disease. scientific evidence to support the medical necessity of PET for the routine At the present time there is controversy regarding spine PET due to inadequate  Preoperative planning    Subarachnoid hemorrhage where no brain aneurysm has been previously identified   (AVF): S C S All requests spinalfor MRA will be forwarded for Medical Director Review. M    pine PET should be considered experimental or investigational and will be ee uspected spinal cord arteriovenous malformation (AVM) or arteriovenous fistula pine MRA imaging is utilized infrequently.

erebrospinal Fluid (CSF) flow studies using MRI are included in CPT RI with RI generally amore definitive study this for purpose. supply to the spinal cord. However, catheter angiography (CPT the spinal cord prior to surgical procedures that might interfere with this blood S S See subarachnoid hemorrhage. definitive study to define possible spinal pathologyresulting in aspinal canal C MRI, catheter angiography is recommended (CPT If suspicion for aspinal AVM or AVF is high based upon the results of the spine study. imaging initial S Required surgicalfor planning. specialist or radiologist to further characterize or diagnose the lesion; or These additional advanced imaging studies are recommended by aspine O - ONC pinal canal MRA may be useful in identifying major intercostal feeder vessels to ee pine MRI of the relevant spine region without and with contrast should be the atheter angiography (CPT ther spinal lesions are seen on routine x : MRA Spinal Canal MRA Spinal Spine PET HD- HD- out and with contrast or aCT without contrast is appropriate if: 31.5 1.5 12.1 : : : Bone (including Vertebral) Metastases : : CT and MR Angiography (CTA and MRA) and Angiography(CTA MR CT and Intracranial AneurysmsIntracranial

® 70496) should be performed and is the most

- rays or anon-

® 72159 or CPT contrast MRI; and

® 72159) is ® www.eviCore.com 70496). ®

code Page 20of62 V2.0.2019 V2.0.2019

Spine Imaging 5. 4. 3. 2. 1. References  Cone SP-2.11: 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Rights All healthcare. eviCore © 2019 https://www.spine.org/researchclinicalcare/qualityimprovement/clinicalguidelines.aspx at: Available 2012. Report. Technical radiculopathy. with herniation disc lumbar of tment andtrea Diagnosis (NASS). Society Spine American North 145. - 141 147: 1987; Med. Intern Arch use. roentgenography Reducing M. Rosenthal AK, Dieh RA, Deyo with flexion with myelopathy spondylotic cervical the of evaluation Preoperative al. et A, Rangel D, Zeitoun L, Zhang 247- Radiology imaging? MR conventional at visible not compromise root nerve demonstrate it does spine: lumbar the of imaging MR Positional al. et M, Zanetti MR, Schmid D, Weishaupt 2013. 13, July Subcommittee of the American Academy of Neurology. Neurology. Neurology. of Academy American the of Subcommittee Assessment andTechnology Therapeutics the of Report disorders. radicular pain and back of e evaluation th for ultrasound onspinal literature the of Review Neurology. of Academy American 31, 2016. 2016. 31, or investigational and will be forwarded to Medical Director Review. Cone- 253. beam CT imagingfor the of cervical spine should be considered experimental - - E1134 36(17): 2011; Journal. Spine imaging. resonance magnetic extension beam CT -beam

- 51:343 1998; 344. Reaffirmed 344. www.eviCore.com .

Accessed May Page 21of62 . 2000; 215: 2000; . V2.0.2019 V2.0.2019 E1139.

Spine Imaging Imaging Guidelines V2.0.2019

SP-3: Neck (Cervical Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma SP-3.1: Neck (Cervical Spine) Pain without and with Neurological Features (Including Stenosis) 22 SP-3.2: Neck (Cervical Spine) Trauma 23

______© 2019 eviCore healthcare. All Rights Reserved. Page 22 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com Features :SP-3.1 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Comments: Imaging: Diagnostic Advanced m Clinical re-e Failure ofrecent(within3months)6-w All ofthefollowingarerequiredprioroadvancedimaging: -1 eaningful contact,seeSP  Theinitial  A  Initialclinicalevaluationperformed. evaluation, re-e evaluation wasperformedinthattimeframe.Thismaybesatisfiedbytheinitial face-t Neck (Cervical Spine) Pain without and with Neurological and with Pain without Spine) (Cervical Neck

(Including Stenosis) (Including valuation aftertreatmentperiod(mayconsistofaace-t

o-f evaluation isnotrequiredwithinthelast60daysifanotherace-t ace evaluationwithinthelast60days. valuation or For surgery see criteria, For the following: (CPT ne without contrastne without (CPT Spi Cervical CT MRI Cervical Spine, without contrast (CPT contrast without Spine, MRI Cervical     .1: ® ®

72126) is appropriate when MRI is contraindicated. CMM CMM CMM CMM without Fusion without General Considerations anothervisit. - - - - 605 : 604: 602: 601: eek trialofprovider-d

Cervical Microdiscectomy Initia Arthroplasty Disc Total Cervical CervicalAnterior and Discectomy Fusion l Posterior Cervical Decompression with or

) irected treatment. ® ® 72125) or CT Myelography o-f

ace evaluationorother ®

72141). www.eviCore.com

Page 23of62 o-f

V2.0.2019 V2.0.2019 ace

Spine Imaging   P  **High risk mechanisms of cervical spine injury may include: :SP-3.2 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Comments: Imaging: Diagnostic Advanced All ractice Notes Plai meaningful seeother contact, SP- re Clinical of Failure weakness, numbness and/or tingling. pathology and/or after 6 weeks of unimproved symptoms of extremity pain, considered when advanced imaging of the spine does not reveal neurocompressive upon history and physical examination findings. Electrodiagnostic testing is often diagnosis of peripheral nerve entrapment and/or a motor/sensory neuropathy based Electrodiagnostic testing (EMGs/NCVs) is generally used to confirm, not establish, a plexopathy, peripheral nerve entrapment and/or motor/sensory neuropathies. C not necessarily justify the addition of thoracic spine advanced diagnostic imaging. Pain radiation patterns from the cervical spine area into the thoracic spine area do Red Flag Indications: See          

of the following are required prior to advancedto imaging: prior required are of the following   

ervical radiculopathy is often confused with n x

quadriparesis/quadriplegia even with minor direct/indirect trauma to the cervical spine which can result in Patients with ankylosing spondylitis are at high risk of cervical spine fractures Not wearing aseatbelt/shoulder harness in a motor vehicle High speed of the vehicle at the time of collision Ejection from the vehicle in a motor vehicle collision Rollover motor vehicle collision Head- Diving accident from Fall Pedestrianin amotor vehicleaccident Head trauma and/or maxillofacial trauma evaluation, re wasevaluation in that performed time frame. initialThe evaluation within is not required the last 60days if another - face A face clinicalInitial evaluation performed. - rays of cervical spinerays of negative fracture for Neck (Cervical Spine) Trauma

- recent recent (within 3months) 6 evaluation after periodevaluation after treatment

on motor vehicle collision without/with airbag deployment - to spine injury withinspine injury last 3 the months below**). (See evaluation not are x Plain beapproved.can co with patients bothFor spondylitis, ankylosing MRI Cervical Spine without (CPTcontrast without MRI Cervical contrast Spine without (CPT - elevation ≥ 3 feet/5 stairs ntrast (CPT ntrast face evaluation withinface last 60days. the - - evaluation or visit. another rays anda6week trial of

® ® 72141) and72141) CT Cervical contrast Spine without (CPT SP-

required for patientsrequired withfor ahigh risk of mechanism cervic 1.1 1.2 ® ® - week trial of 72125). :

: : )General Considerations Red Flag Indications Flag Red

(may consist of a face

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72141) or CT Cervical Spine

directed treatment directed

- to - face evaluation or face collision

. www.eviCore.com

Page 24of62 to ® ® - face face V2.0.2019 V2.0.2019 72125) - al al

Spine Imaging 9. 8. 7. 6. 5. 4. 3. 2. 12. 11. 10. 1. R 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 eferences Imaging. ACR Appropriateness Criteria Appropriateness ACR Imaging. W BN, Weissman RH, Daffner Clinical Medicine Clinical Eyre A. Overview and comparison of NEXUS and Canadian C Canadian and NEXUS of comparison and Overview A. Eyre JAMA, patients. trauma stable Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C Canadian The al. et KL, Vandemheen GA, IG, Wells Stiell Med, Engl N J Group. Study Utilization out injury to the cervical spine in patients with blunt trauma. National Emergency X Emergency National trauma. blunt with patients in spine cervical the to injury out rule to criteria clinical of aset of Validity MI. Zucker KH, Todd AB, Wolfson Mower JR, WR, Hoffman Radiology, spondylitis. ankylosing complicating injuries spine cervical of MRI SK. MP, Koskinen Koivikko Diagnosis and Management. JAAOS, Management. and Diagnosis Spondylitis: Ankylosing with Patients in Fractures Spinal F. Shen, D, B, Samartzis, Werner, - 2001;7(1):142 A Continuum, Part pain back and al. et Neck MW, Devereaux ED, Covington KH, Levin - 2005;11(6):94 Care, Palliative and andneck back of treatment and diagnosis Precision M. Karasek N, Bogduk spine fractures. CJEM fractures. spine cervical of risk the with mechanism injury of Association al. et CM, Clement IG, Stiell WL, Thompson https://acsearch.acr.org/docs/3094107/Narrative/ 2017. 20, onOctober Accessed 2016. Origin: of Date (ACR); Radiology of College https://acsearch.acr.org/docs/69426/Narrative/ 2017. 20, onOctober Accessed 2013. Review: Last 1998. https://acsearch.acr.org/docs/69359/Narrative/ 2017. 20, onOctober Accessed 2012. Review: Last 1999. Origin: of Date (ACR); Criteria in Patients with Trauma. N EnglMed Trauma. with J Patients in Criteria C Canadian al. The et RD, McKnight CM, Clement IG, Stiell Criteria Appropriateness Expert al. et. FD, Beaman MJ, Kransdorf SA, Bernard Criteria Appropriateness ACR Imaging. Musculoskeletal on Panel Expert al. et. PD, Angevine BN, JS, Weissman Newman

- 813 (9): 37 2008; 151. - 2006;3:12 ,

- 11(1):14 2009; ® ® : Chronic Back Pain: Suspected Sacroiliitis/Spondyloarthropathy. American Sacroiliitis/Spondyloarthropathy. Suspected Pain: Back Chronic : Origin: of Date (ACR); Radiology of College American Pain. Neck Chronic : 15. 819.

ippold FJ, et. al. Expert Panels on Musculoskeletal and Neurologic Musculoskeletal on Panels Expert al. et. ippold FJ, - 2001;286(15):1841 136.

2016; 24;(4):241 2016; 22.

- 2000;343(2):94 ® : Suspected Spine Trauma. American College of Radiology of College American Trauma. Spine Suspected :

. - 2003;349:2510 . 1848.

Panel on Musculoskeletal Imaging. ACR Imaging. Musculoskeletal on Panel - 99. 249. - - Spine Rule versus the NEXUS Low NEXUS the versus Rule Spine spine rule for radiography in alert and alert in radiography for rule spine - 8. spine rules. rules. spine

pain. American Journal of Journal American Continuum: Pain Continuum: - www.eviCore.com Radiography.

Page 25of62 V2.0.2019 V2.0.2019 Etiology, Skeletal - Risk

Spine Imaging Imaging Guidelines V2.0.2019

SP-4: Upper Back (Thoracic Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma SP-4.1: Upper Back (Thoracic Spine) Pain without and with Neurological Features (Including Stenosis) 26 SP-4.2: Upper Back (Thoracic Spine) Trauma 26

______© 2019 eviCore healthcare. All Rights Reserved. Page 26 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 2. 1. R   P  Trauma Spine) (Thoracic Back Upper SP-4.2: Features Neurological and with Pain Spine) without (Thoracic Back Upper SP-4.1: 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Diagnostic Imaging: Diagnostic Advanced All Comments: Imaging: Diagnostic Advanced All ractic eference Plain x Plain contact, meaningful see re Clinical 3 (within recent of Failure contact, meaningful see re Clinical of Failure recent (within 3months) 6 Imaging. ACR Appropriateness Criteria Appropriateness ACR Imaging. and Neurologic Musculoskeletal on Panels Expert al. et. FJ, BN, Wippold RH, Weissman Daffner 2017. Elsevier; PA: Philadelphia, requisites. the Neuroradiology: DM. Yousem R, Nadgir clinical features indicating athoracic spine disorder. back pain with radiation toward the thoracic region unless there are documented A around the rib cage following the sensory distribution of an intercostal nerve. the trunk Thoracic radiculopathy presents with pain radiation from the thoracic spine Red Flag Indications: See https://acsearch.acr.org/docs/69359/Narrative/ 2017. 20, onOctober Accessed 2012. Review: Last 1999. Origin: of Date (ACR);

of the following are required prior to advancedto imaging: prior required are of the following of       dvanced diagnostic imaging is generally not appropriate in evaluation of axial low

the are required priorfollowing to advanced imaging: e Notes: evaluation, re wasevaluation in that performed time This mayframe. be bysatisfied initial the initialThe evaluation within is not required the last 60days if another - face A face clinicalInitial evaluation performed. evaluation, re wasevaluation in that performed time frame. initialThe evaluation within is not required the last 60days if another - face A face clinicalInitial evaluation performed. - rays of tho rays of s s - - evaluation after periodevaluation (may after treatment consist of a face periodevaluation (may after treatment consist of a face . A .

- - to to t upper thoracic spine levels, the pain radiation is from the thoracic spine - -

face evaluation withinface last 60days. the face evaluation withinface last 60days. the racic spine negative for fracture. spinenegative for racic - -

evaluation or visit. another evaluation or visit. another without contrast (CPTcontrast without MRI Thoracic Spine without contrast (CPT (CPT A CT spine without contrastThoracic (CPT MRI Thoracic Spine without contrast (CPT SP SP

months) 6 - -

1.1 1.1 ® ® (Including Stenosis) (Including 72129) is appropriate when MRI is contraindicated. SP- : :

General Considerations General Considerations 1.2 - - week trial of week trial of ® : : : Suspected Spine Trauma. American College of Radiol of College American Trauma. Spine Suspected : Red Flag Indications Flag Red

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CT Thoracic Spine CT Thoracic

CT Myelography

Page 27of62 to to

- - face face face face V2.0.2019 V2.0.2019 around

ogy

Spine Imaging Imaging Guidelines V2.0.2019

SP-5: Low Back (Lumbar Spine) Pain/Coccydynia without Neurological Features SP-5.1: Low Back (Lumbar Spine) Pain without Neurological Features 28 SP-5.2: Coccydynia without Neurological Features 28

______© 2019 eviCore healthcare. All Rights Reserved. Page 28 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com post Coccydynia is often reported by patients as “tailbone” pain that is usually idiopathic or P  Features Neurological without Coccydynia SP-5.2: Features Neurological Pain without Spine) (Lumbar Back Low SP-5.1: 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Comments: Di Advanced x Plain All Comments: Imaging: Diagnostic Adva All ractice Notes meaningful contact, meaningful see re Clinical of Failure recent (within 3months) 6- contact, meaningful see re Clinical r of Failure agnostic Imaging:agnostic Red Flag Indications: See

-       of the following are required prior to advanced imaging: of the following are required prior to advanced imaging: traumatic and generally follows abenign course.

nced - evaluation wa in that performed s time This may be frame. bysatisfied initial the evaluation, re wasevaluation in that performed time This mayframe. be bysatisfied initial the initialThe evaluation within is not required the last 60days if another - face A face clinicalInitial evaluation performed. evaluation, re initialThe evaluation is not required A face clinicalInitial evaluation performed. rays of the sacrum/coccyxrays of negative are fracture for - - evaluation after periodevaluation (may after treatment consist of a face periodevaluation (may after treatment consist of a face ecent (within 3months) 6-

- - to to - - face evaluface ati face evaluation withinface last 60days. the - -

evaluation or visit. another evaluation or visit. another contraindicated. A CT pelvis contrast without (CPT MRI pelviswithout contrast (CPT For surgery see criteria, For (CPT A CT lumbar spine without contrast (CPT SpineMRI Lumbar without contrast (CPT SP SP - - 1.1 1.1 ® ® on within last 60days. the 72132) is appropriate when MRI is contraindicated SP- : :

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Arthroplasty

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Spine Imaging 3. 2. 10. 1. References 9. 11. 8. 12. 5. 4. 7. 6. 13. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 14. 15. 16. 17. 21. 20. 19. 18. 22. 23. 24. © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 . https://www.aaos.org/guidelines/?ssopc=1 Guidelines. Practice Clinical II). and I (phase (acute) pain/sciatica back low on guidelines clinical (AAOS) Surgeons Orthopedic of Academy American - 41:477 , AAOS Spine, 4: Update Knowledge Orthopaedic M. Smuck RD, Rao, doi:10.1093/rheumatology/keh008. Abnormalities corr Abnormalities spondyloarthropathy. seronegative early in sacroiliitis of imaging resonance KB. Magnetic Puhakka - 2001;7(1):142 Continuum A. pain part back and al. et Neck MW, Devereaux ED, Covington KH, Levin J American Yield. and Pain: Indications Back Low for MRI Spine Lumbar JG. Jarvik B, Roudsari - 147:478 2007; Society. Pain American the and Physicians of College American the from guideline practice clinical A joint pain: lowback of treatment and Diagnosis al. V, et A, Snow Qaseam R, Chou doi:10.1056/nejm199810083391502. Physicians. of College American the from care health high- for Advice pain: back low for imaging Diagnostic al. et DK, A, Owens Qaseem R, Chou 2000. Society; Spine American specialists. care spine multidisciplinary Herniated guidelines. onclinical Force Task NASS 2017. 1, August Accessed Pain. Pain. wi Patients of Treatment the for Booklet Educational an of Provision and Manipulation, Chiropractic Therapy, Physical of A Comparison W. Barlow J, Street M, Battié RA, Deyo DC, Cherkin herniation. al. et TD, Tosteson JD, Lurie JN, Weinstein - 195:550 Sept; 2010 AJR, yield. and Indications pain: back low for MRI spine Lumbar JG. Jarvik B, Roudsari Academy of Orthopaedic Surgeons Orthopaedic of Academy (American AAOS IL.: Rosemont, 2009. review orthopaedic comprehensive AAOS ed. JR, Lieberman - 2009;22(1):62 Med, Fam Deyo RA, Mirza - 137:586 2000; Med, Intern Ann imaging. on emphasis with pain low back of evaluation Diagnostic Deyo R. JG, Jarvik - 195:550 yield. and Indications pain: back low for MRI spine Lumbar JG. Jarvik B, Roudsari Med, patients of treatment the for booklet educational an of provision and manipulation, chiropractic therapy, physical of A comparison al. et M, Battie RA, Deyo DC, Cherkin of low back pain Radiol, . low back of treatment the in making decision clinical on imaging of Influence JE. Andrew FJ, Gilbert MGC, Gillan Radiol Clin N Am, N Clin Radiol imaging. resonance onmagnetic emphasis with assessment imaging practical Current arthritis: idiopathic Juvenile PS. Babyn EY, Lee R, Restropo approach. multimodality A arthritis: idiopathic juvenile of Imaging JL. Demertzis AJ, White G, Khanna EF, Sheybani pain. back low Persistent EJ. Carragee pain. back Low JN. RA, Wenstein Deyo 2005; 32:10. 2005; Rheumatology, - multiple A imaging. resonance by magnetic al. et X, Baraliakos DMFM, Heijde Der Van KGA, Hermann RBM, Landewe - 4005 56(12): spondylitis. ankylosing with patients in inflammation joint and sacroiliac spinal both reduces significantly Adalimumab al. et RD, P, Inman Rahman D, Salonen RGW, Lambert American College of Physicians. Physicians. of College American High- for Advice Pain: Back Low for Imaging Diagnostic R. Chou ournal of Roentgenology. of ournal

- 339(15):1021 Oct; 1998 New England Journal of Medicine. of Journal England New 559. 559. Spine, 4014. 151. 491.

SK, Turner JA, et al. Overtreating chronic back pain: time to back off? J Am Board Am J off? back to time pain: back chronic Overtreating al. et JA, Turner SK,

elated to clinical and laboratory findings andlaboratory clinical to elated - 33(25):2789 2008; 597. Radiographics,

- 220:393 2001; 68.

- 2010;195(3):550 1029. . Medicine of Internal Annals ); 2009. ); 2800.

Unremitting low back pain. 1st ed. Burr Ridge, IL: North IL: Ridge, Burr ed. 1st pain. back low Unremitting Med, J Engl N

J Med, J Engl N - 1253 33(5): 2013; 395. - 1998;339(15):1021

The Journal of Journal The experiment. reliability reader Surgical versus nonoperative treatment for lumbar disc lumbar for treatment nonoperative versus Surgical 559. doi:10.2214/ajr.10.4367. 559. : Phase III clinical guidelines for guidelines clinical III Phase In: disc. Ann Intern Med, Ann Intern

- 352:1891 2005; - 344(5):363 Feb; 2001 . Rheumatology . 1273. 1029.

- doi:10.7326/0003 2011;154(3):181. Value Health Care From the From Care Health Value

2013; 51: 703- 51: 2013;

N Engl J Engl N pain. back low with

- 2011:154:181 1898. Arthritis & Rheumatism, Arthritis - 2003;43(2):234 .

Scoring sacroiliac joints sacroiliac Scoring 370. 478. 719. AJR, www.eviCore.com , Med Ann Intern 189.

th Low Back Low th Page 30of62

2010 Sept; 2010 V2.0.2019 V2.0.2019 237. value

2007;

Spine Imaging 34. 25. 35. 26. 28. 27. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 30. 29. 31. 32. 33. © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 2015. Accessed on October 20, 2017. https://acsearch.acr.org/docs/69483/Narrative/ 2017. 20, on October Accessed 2015. pain? JAMA pain? back low about us tell examination physical and history the can DL. What Kent J, Rainville RA, Deyo Med, imaging. on emphasis with pain low back of evaluation Diagnostic Deyo R. JG, Jarvik 100:169 Patrick doi:10.1148/radiol.2372041509. Neuroradiology. onoutcome. effect and role prognostic and their findings imaging MR and radiculopathy: pain back low Acute al. et J, Ross N, Obuchowski M., Modic 10.1001/jamainternmed.2016.6274. pain- back low for imaging inappropriate avoiding to barriers of perceptions Clinicians’ al. et M, Dredze EC, Leas JW, Ayers patients. in older outcomes clinical painwith back for imaging early of Association BA, al. et Comstock LS, Gold JG, Jarvik - outcome and treatment on CT or imaging MR early of influence pain: back Low al. et MG, AM, Gillan Grant FJ, Gilbert doi:10.1097/BRS.0000000000001790. Spine Journal Spine sciatica. and/or pain back low with patients in year 1 upto of a period over change findings MRI Do al. et D, Steffens J, Hush J, Panagopoulos doi:10.1148/radiol.2312030886. observational study in primary care. care. primary in study observational and trial trolled con pain: a randomized low back for D, al.et Radiography S, S, Dundas Kerry Hilton low back pain. back low acute simple with patients of outcomes the in radiography spine lumbar of role The H. Kalim N, Djais Criteria Appropriateness ACR Imaging. on Neurologic Panel Expert al. et. J, Burns DF, Broderick ND, Patel

- 137:586 2000; ® N, Emanski E, Knaub MA. Acute and Chronic Low Back Pain. Med Clin N Am. 2016; Am. N Clin Med Pain. Back Low Chronic and Acute MA. Knaub E, Emanski N, – : Low Back Pain. Back Low : 181. . 1992; 268(6): 760- 268(6): 1992; . APLAR Journal of Rheumatology of Journal APLAR 597. multicenter randomized trial. Radiology. trial. randomized multicenter American College of Radiology (ACR); Radiology of College American knowing is not enough. JAMA enough. not is knowing JAMA. 765.

(11): 1143 (11): 2015;313 - 52:469 2002; . Practice General of Journal British - 45 8: 2005; . - 1153. doi:10.1001/jama.2015.1871. 1153. . - 42:504 2017; . - 311(14):1399 2014; 50.

- 231:343 2004;

Date of Origin: 1996. Last Review: Last 1996. Origin: of Date - 237:597 2005; 512. 1400. doi: 1400. 351. 604. www.eviCore.com

Ann Intern Ann 474. . Page 31of62 V2.0.2019 V2.0.2019

Spine Imaging Imaging Guidelines V2.0.2019

SP-6: Lower Extremity Pain with Neurological Features (Radiculopathy, Radiculitis, or Plexopathy and Neuropathy) With or Without Low Back (Lumbar Spine) Pain SP-6.1: Lower Extremity Pain with Neurological Features (Radiculopathy, Radiculitis, or Plexopathy and Neuropathy) with or without Low Back (Lumbar Spine) Pain 32 SP-6.2: Low Back (Lumbar Spine) Trauma 32

______© 2019 eviCore healthcare. All Rights Reserved. Page 32 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com     Trauma Spine) Back Low (Lumbar SP-6.2: Spi (Lumbar Back Low without or with Neuropathy) and or Plexopathy Radiculitis, (Radiculopathy, SP-6.1: Lower Extremity Pain Neurological Featureswith 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Diagnost Advanced All Comments: Imaging: Diagnostic Advanced All Plain x Plain contact, meaningful see re Clinical of Failure recent (within 3months) 6 S contact,meaningful see re Clinical of Failure recent (within 3months) 6- ee Plexus Lumbar and/or Lumbosacral Plexopathy: Paresthetica PN : See Sciatic Neuropathy, Femoral Neuropathy, Peroneal Neuropathy and Definitionsradiculopathy, of Red Flag Indications: See SP-

      of the following are required prior to advanced imaging: of the following are required prior to advanced imaging:

SP- evaluation, re wasevalua in that performed tion time frame. initialThe evaluation within is not required the last 60days if another - face A face clinicalInitial evaluation performed. evaluation, re wasevaluation in that performed time frame. initialThe evaluation within is not therequired last 60days if another - face A face clinicalInitial evaluation performed. - rays of lumbar spinerays of negative fracture. for 9.1 ic Imaging: - - evaluation after periodevaluation (may after treatment consist of a face periodevaluation (may after treatment consist of a face

: : - - Lumbar Stenosis Spinal to to - - face evaluation withinface last 60days. the face evaluation withinface last 60days. the - -

evaluation or visit. another evaluation or visit. another For surgery see criteria, For the following: without contrast (CPTcontrast without SpineMRI Lumbar without contrast (CPT (CPT A CT lumbar spine without contrast (CPT SpineMRI Lumbar without contrast (C SP- SP -2:    - :1.1 1.1 ®

Focal Neuropathy Focal 72132) is when appropriate MRI is contraindicated. CMM CMM CMM :

radiculitis and radicular pain: General Considerations General Considerations 1.2 - - - - 609 : 608: 606: week trial of provider week trial of : :

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Lu Lumbar Decompression Lumbar Microdiscectomy Lumbar

mbar Fusionmbar (Arthrodesis) ® 72131).

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Definitions

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Spine Imaging 10. 11. 9. 8. 12. 3. 7. 6. 2. 13. 1. R  5. 4. 14. 15. 16. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 17. 18. 19. 20. 21. © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 eferences doi:10.1056/nejm199810083391502. - 2001;7(1):142 Continuum, A. pain part back and al. et Neck MW, Devereaux ED, Covington KH, Levin Pain. Pain. Back Low with Patients of Treatment the for Booklet Educational an of Provision and Manipulation, Chir Therapy, Physical of A Comparison W. Barlow J, Street M, Battié RA, Deyo DC, Cherkin - 147:478 2007; Society. Pain American the and Physicians of College American the from guideline practice clinical A joint pain: lowback of treatment and Diagnosis al. V, et A, Snow Qaseam R, Chou doi:10.1056/nejmoa070302. Academy of Orthopaedic Surgeons); 2009. Surgeons); Orthopaedic of Academy ed. JR, Lieberman . aaos.org/guidelines/?ssopc=1 https://www. Guidelines. Practice Clinical II). and I (phase (acute) pain/sciatica back low on guidelines clinical (AAOS) Surgeons Orthopedic of Academy American Spondylolisthesis. Spondylolisthesis. Degenerative Lumbar for Treatment Nonsurgical versus Surgical al. et TD, Tosteson JD, Lurie JN, Weinstein Roentgenology of Journal American Yield. and Pain: Indications Back Low for MRI Spine Lumbar JG. Jarvik B, Roudsari Fam Med, Fam Am Board J off? back to time pain: back chronic Overtreating al. et JA, Turner SK, Mirza RA, Deyo Rao, RD, Smuck M. Orthopaedic Knowledge Update 4: Spine 4: Update Knowledge Orthopaedic M. Smuck RD, Rao, - 2004;43(2):234 Rheumatology findings. laboratory and clinical to associated Abnormalities spondyloarthropathy. seronegative early Puhakka KB, Juri Puhakka - doi:10.7326/0003 Physicians. of College American High- for Advice Pain: Back Low for Imaging Diagnostic R. Chou Ameri North IL: Ridge, Burr ed. 1st pain. back low Unremitting specialists. care spine multidisciplinary for guidelines clinical III Phase In: disc. Herniated guidelines. onclinical Force Task NASS 2017. 1, August Accessed studies is documented. See MS apparent lumbar radiculopathy unless a separate recognized indication suchfor Advanced imaging Med, Med, Intern Ann imaging. on emphasis with pain low back of evaluation Diagnostic Deyo R. JG, Jarvik - 195:550 yield. and Indications pain: back low for MRI spine Lumbar JG. Jarvik B, Roudsari Med, Med, J Engl N pain. back low with patients of treatment the for booklet educational an of provision and manipulation, chiropractic therapy, physical of A comparison al. et M, Battie RA, Deyo DC, Cherkin Radiol, pain. Radiol, low back of treat the in making decision clinical on imaging of Influence JE. Andrew FJ, Gilbert MGC, Gillan Deyo RA, Wenstein JN. Low back pain. back Low JN. RA, Wenstein Deyo Carragee EJ. Persistent low back pain. back low Persistent EJ. Carragee multimodality approach. approach. multimodality A arthritis: idiopathic juvenile of Imaging JL. Demertzis AJ, White G, Khanna EF, Sheybani Radiol Cli Radiol imaging. resonance onmagnetic emphasis with assessment imaging practical Current arthritis: idiopathic Juvenile PS. Babyn EY, Lee R, Restropo Rheumatology - multiple A imaging. resonance by magnetic joints sacroiliac Scoring al. et X, Baraliakos DMFM, Heijde Der Van KGA, Hermann RBM, Landewe - 2000;137:586 - 339(15):1021 Oct; 1998 - 1998;339(15):1021 . Medicine of Journal England New can Spine Society; 2000. Society; Spine can 559.

- 2009;22(1):62 , 2005; 32:10. 2005; , 151. 491. k AG, Schiottz AG, k - 4819 AAOS comprehensive orthopaedic review 2009 review orthopaedic comprehensive AAOS 597.

of the hip or pelvis is not generally required in the evaluation of 154 Radiographics - 220:393 2001; 68. - 2010;195(3):550 . -3- 1029. - 201102010 237. - Christensen B, et al. Magnetic resonance imaging of sacroiliitis in sacroiliitis of imaging resonance Magnetic al. et B, Christensen - 2007;356(22):2257 . Medicine of Journal England New - 2011;154(3):181 . Medicine of Internal Annals - - 1253 33(5): 2013; , 24 - 352:1891 2005; Med, J Engl N - 344(5):363 Feb; 2001 Med, J Engl N 395. : : 00008. Hip The Journal of Journal The experiment. reliability reader 559. doi:10.2214/ajr.10.4367. 559.

in the Musculoskeletal Imaging Guidelines. n N Am N n 1273. 1029. - 41:477 AAOS, , Value Health Care From the From Care Health Value , 2013; 51: 703- 51: 2013; , . Rosemont, IL.: AAOS (American AAOS IL.: Rosemont, . 1898. 370. 478. 189. 719. 2010 Sept; 2010 AJR, www.eviCore.com Ann Intern Med Ann Intern

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Spine Imaging 30. 22. 23. 25. 24. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 26. 27. 28. 29. © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 2015. Accessed on October 20, 2017. https://acsearch.acr.org/docs/69483/Narrative/ 2017. 20, on October Accessed 2015. https://acsearch.acr.org/docs/69359/Narrative/ 2017. 20, onOctober Accessed 2012. Review: Last 1999. Origin: of Date (ACR); Imaging. ACR Appropriateness Criteria Appropriateness ACR Imaging. and Neurologic Musculoskeletal on Panels Expert al. et. FJ, BN, Wippold RH, Weissman Daffner - 4005 56(12): spondylitis. ankylosing with patients in inflammation joint and sacroiliac spinal both reduces significantly Adalimumab al. et RD, P, Inman Rahman D, Salonen RGW, Lambert - 137:586 2000; Med Intern Ann imaging. on emphasis with pain low back of evaluation Diagnostic Deyo R. JG, Jarvik - outcome and treatment on CT or imaging MR early of influence pain: back Low al. et MG, AM, Gillan Grant FJ, Gilbert doi:10.1097/BRS.0000000000001790. Spine Journal Spine sciatica. and/or pain back low with patients in year 1 upto of a period over change findings MRI Do al. et D, Steffens J, Hush J, Panagopoulos doi:10.1148/radiol.2312030886. doi:10.1148/radiol.2372041509. and their prognostic role and effect on outcome. Neuroradiology onoutcome. effect and role prognostic and their findings imaging MR and radiculopathy: pain back low Acute al. et J, Ross N, Obuchowski M., Modic follow A, Vleggeert Barzouhi pain? JAMA pain? back low about us tell examination physical and history the can DL. What Kent J, Rainville RA, Deyo Criteria Brod ND, Patel - up assessment of sciatica. N Engl Med sciatica. J of assessment up ® : Low Back Pain. American College of Radiology (ACR); Date of Origin: 1996. Last Review: Last 1996. Origin: of Date (ACR); Radiology of College American Pain. Back Low : . 1992; 268(6): 760- 268(6): 1992; . 4014. erick DF, Burns J, et. al. et. al. J, Burns DF, erick 597. - Lankamp C, Lycklama a Nijehold G, et al. Magnetic resonance imaging in imaging resonance Magnetic al. et G, aNijehold Lycklama C, Lankamp multicenter randomized trial. Radiology. trial. randomized multicenter 765. ® Expert Panel on Neurologic Imaging. ACR Appropriateness ACR Imaging. on Neurologic Panel Expert f Radiology of College American Trauma. Spine Suspected : . . 2013; 368;11: 999- 368;11: 2013; . - 42:504 2017; . - 237:597 2005; .

- 231:343 2004; 1007. , 2007; , & Rheumatism Arthritis 512. 351. 604. www.eviCore.com

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Spine Imaging Imaging Guidelines V2.0.2019

SP-7: Myelopathy SP-7.1: Myelopathy 36

______© 2019 eviCore healthcare. All Rights Reserved. Page 36 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com samehand flexes. distal phalanx. A positive test is noted if the interphalangeal joint of the thumb of the – sign Hoffman’s toes. negative test occurs with no movement of the toes at all or uniform bunching up of the occurs with extension of the great toe with flexion andsplaying the of other toes. A the foot from the calcaneus along the lateral border to the forefoot. Babin the upper or lower extremities. the leg kept straight. table, the examiner passively flexes the patient’s head and one hip simultaneously with Lhermitte’s sign Practice Notes       :SP-7.1 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019     F C potential myelopathy. Conservative treatment is not arequirement for advanced imaging in patients with       contrast,are C reasonably suspected myelopathy. Advanced imaging is generally appropriate in the initial evaluation of documented or escape sign. Sensory level andurinary incontinence/retention may beseen. clo with hyperreflexia and upgoing toes (positive Babinski), Hoffman E myelitis, MS, etc.), neoplastic disease or spinal cord infarction. usually secondary to spinal cord compression, but also inflammation (transverse Myelopathy is the development of abnormal spinal cord function with long tract signs or surgery criteria, see the following: xamination findings may include loss of manual dexterity, spastic legs and ataxia

T/Myelography scan can also be considered, especially surgical for planning. ervical ski’s sign nus, Lhermitte’s sign, crossed radial reflex, inverted radial reflex and finger - CMM - CMM - CMM C Hoffman Unexplained Babinski’ssign. Sustained,prominent, andunexplained Lhermitte’s symptoms. Post- Suspected tethered cord. I nitial evaluation of reasonably suspected myelopathy. MM- Myelopathy , traumatic syrinx with increased spinal pain or a worsening neurological thoracic : 605: 604: 602: 601: n appropriate for: – – ’s sign. ’s – –

Cervical Microdiscectomy Posterior Cervical Decompression with or without Cervical Total Disc Arthroplasty Anterior Cervical Discectomy and Fusion

Theexaminer holds the patient’s middleger fin briskly and the flicks The examiner runs asharp instrument along the plantar surface of With theWith patient in the long leg sitting position on the examination

, and, lumbar A positive test occurs if there is sharp pain down the spine and into

spine MRI without contrast, or without and with sign.

A positive test

n Fusion ’s sign,sustained www.eviCore.com

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Spine Imaging 5. 8. 7. 6. 4. 3. 2. 1. References 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Criteria Appropriateness ACR Imaging. on Neurologic Panel Expert et. JM, al. Aulino PD, Angevine Roth CJ, 1976. 1976. River. Saddle Upper Hall. Prentice Extremities. and Spine the of Examination S. Physical Hoppenfeld 2002. Philadelphia. Saunders. edition. 4th Assessment, Physical Orthopedic DJ. Magee with flexion with myelopathy spondylotic cervical the of evaluation Preoperative al. et A, Rangel D, Zeitoun L, Zhang lesions. cord spinal of images resonance magnetic and features histopathologic between K. Correlation Nagashima M, Takahara K, Hatayama I, Ohshio 820- myelopathy. spondylotic cervical for levels decompression select to MRI dynamic preoperative of usefulness clinical The al. Y et Y, Mikami Tsuji T, Harada 475- myelopathy. spondylotic in cervical change intensity signal of classifications MRI different of value prognostic of Comparison AP. Shetty S, Rajasekaran A, Avadhani M and Stenosis Spondylotic Cervical for Modalities Imaging JM. Obyrne A, S, Poynton Eustace J, Butler C, Green 2015. Accessed on October 20, 2017. https://acsearch.acr.org/docs/69484/Narrative/ 2017. 20, on October Accessed 2015. 826. 485. ® : Myelopa - - E1134 36(17): 2011; Journal. Spine imaging. resonance magnetic extension yelopathy. thy. American College of Radiology (ACR); Date of Origin: 1996. Last Review: Last 1996. Origin: of Date (ACR); Radiology of College American thy. Advances in Orthopedics Advances Spine - 2012;2012:1 . - 18:1140 1993, , , 2010;28: , Imaging Resonance Magnetic 4. doi:10.1155/2012/908324. 4. 1149. Spine Journal, Spine www.eviCore.com

. Page 38of62 V2.0.2019 V2.0.2019 E1139.

2010;10:

Spine Imaging Imaging Guidelines V2.0.2019

SP-8: Lumbar Spine Spondylolysis/Spondylolisthesis SP-8.1: Spondylolysis 39 SP-8.2: Spondylolisthesis 40

______© 2019 eviCore healthcare. All Rights Reserved. Page 39 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com             :SP-8.1 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019   crit surgery For  medically necessary interarticularis fracture non- isthmic pars interarticularis defect whether it is developmental or the result of a pars B F Indications provider T T T T S M Lumbar spine CT without contr   I imaging is generally not indicat Spondylolysis is most often an incidental finding onplain x f plain x plain f or pediatric spondylolysis, S hereistreatment failure following here is a documented need for preoperative planning o s o evaluate bony anatomy ony healing cannot be achieved non- PECT bone scan is negative

RI is contraindicated reaction in early spondylolysis cases which radiographically are occult. - CMM (Spine) C was determined to have healing potential on a prior CT (i.e., non- spinal level is indicated to monitor healing of a pars interarticularis fracture that R     following: Lumbar spine MRI without contrast (CPT 9 tate a lesion seen on SPECT bone scan

9mTc MM- epeat lumbar spine CT without contrast (CPT Spondylolysis ■ T T T SPECT bone scan is negative orthosis and - hereistreatment failure following here is a documented needpreoperative for planning o evaluate stressfor reaction in - directed treatment with clinical re- rays are negative, equivocal or indeterminate and clinical suspicion is high: : 609: 603: the potential for falsenegative results. Note -

MDP SPECT bone scan ( .

Lumbar Fusion (Arthrodesis) Electrical eria, see the following: : MRI is not appropriate in provider

in this setting.

and Low Frequency Ultrasound BoneGrowth Stimulation union. Repeat advanced diagnostic imaging is not - directed treatment with clinical re- ee ast (CPT ast ed. PEDSP- 6 weeks immobilization with aspinal orthosis and CPT surgically in anestablished well defined ® bone, to visualize nerve roots 2.4 ® 72131)

the the 6 weeks immobilization evaluation. 78320) is indicated to identify stress

: : ® Spondylolysis early diagnosis of spondylolysisdue to 72148) is appropriate for ANY of the ANYofthe following for ® 72131) of the symptomatic

See - SP- rays, andadvanced

evaluation. 1.2

: with aspinal Red Flag Red for for sclerotic lesion). www.eviCore.com

ANY

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of theof

Spine Imaging 10. 9. Leon 8. 7. 6. 2. 5. 4. 3. 11. 1. R   Practice Notes   :SP-8.2 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 eferences - 2013;41:169 Med. Sports J Am Imaging. Resonance Magnetic by Athletes Young in Spondylolysis Lumbar Occult Radiographically of Diagnosis al. et A, Kobayashi - 2000;34:415 Medicine Sports of Journal British review. acritical Spondylolysis: SA. Herring CJ, Standaert - 2009;8:20 Rep. Med Sports Curr Gymnastics. of Sport the in Injuries B. Spine Lemmen D, Kruse ed. JR, Lieberman - 1998;53:723 Radiol. Clin spondylolysis. lumbar of investigation radiological The et. CJ, Harvey - 2013;29:209 Syst. Nerv Childs focus. anatomic an with review comprehensive a L5 spondylolysis/spondylolisthesis: al. P, et Foreman 10.1016/j.spinee.2014.08.006. - non and mobile of diagnosis in the imaging resonance magnetic of Sensitivity al. et C, S, Buchanan Kouk BD, Kuhns 2009: Surgeons); Orthopaedic of Academy - 86:225 2004; Br. Surg Joint Bone J treatment. conservative after outcome radiologic the adolescents: and children in spine lumbar the of interarticularis pars in the defects of Union al. et K, Sairyo S, K, Katoh Fujii Spine 4: Update Knowledge Orthopaedic M. Smuck RD, Rao, - 43(2):234 Feb; 2004 Rheumatology, findings. laboratory and clinical to correlated Abnormalities spondyloarthropathy. seronegative early  frequently asymptomatic. be involved. Spondylolisthesis is often an incidental finding on plain x vertebra, most commonly at L4- not clinically significant) displacement of one vertebra in relation to an adjacent S asymptomatic. interarticularis defects can be an incidental finding onplain x the lumbar spine and may be acute or chronic and unilateral or bilateral. Pars athletes and others whose activities involve repetitive flexion/extension loading of Stress reactions and stress fractures of the pars interarticularis are most common in   For surgery criteria, see the following:   contrast CT lumbar spine without contrast (CPT Puhakka KB, Jurik AG, Schiottz AG, Jurik KB, Puhakka pondylolisthesis is the forward (anterolisthesis) or backward (retrolisthesis, usually

(see F - CMM C See Preoperative evaluation; or e A, et al. Lumbar spondylolysis: a review. areview. spondylolysis: Lumbar al. et e A, ailure of 6 week trial of provider MM- Spondylolisthesis SP- SP- (CPT : 609: 608: 422. 31. 1.2 : : 1.1 mobile L4- mobile ® Lumbar Fusion (Arthrodesis) Lumbar Decompression : : 72148) can be considered after plain x AAOS comprehensive orthopaedic comprehensive AAOS Red Flag Indications Flag Red General Considerations); 5 degenerative spondylolisthesis. The Spine Journal; 2014. doi: 2014. Journal; Spine The spondylolisthesis. 5 degenerative - Christensen B, et. Christensen

237. 5 andL5- 16. - 771 - directed treatment and clinical re -

® 775. Skeletal Radiol. Skeletal 72131) or MRI lumbar spine without S1, although other levels of the

al. Magnetic resonance imaging of sacroiliitis in sacroiliitis of imaging resonance Magnetic al.

review 2009 review

- 41:477 AAOS, , 76.

- 2011;40:683 - ray the for following: . Rosemont, IL.: AAOS (American AAOS IL.: Rosemont, . - rays andis frequently 700. 478. - www.eviCore.com ray andis evaluation

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spine may V2.0.2019 V2.0.2019 . 28. 28.

Spine Imaging Imaging Guidelines V2.0.2019

SP-9: Lumbar Spinal Stenosis SP-9.1: Lumbar Spinal Stenosis 42

______© 2019 eviCore healthcare. All Rights Reserved. Page 42 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 8. 3. 2. 1. References peripheral neuropathy. lumbar spinal stenosis should include peripheral vascular disease, hip disorders and walking andrelieved fairly rapidly by stopping and rest. The differential diagnosis for differentiated from vascular claudication (leg/calf pain) that is often aggravated by and is often relieved by sitting andbending forward. Neurogenic claudication should be that is aggravated by walking, especially down hills or stairs, withprolonged standing population. Neurogenic claudication is a common symptom of lumbar spinal stenosis common cause of buttock/low back and/or leg pain (neurogenic claudication) in this is usually adegenerative condition of the aging spine which elements within the spinal canal that include spinal nerve roots and the cauda equina Lumbar spinal stenosis refers to a decrease in the space available for the neural Practice Notes    :SP-9.1 7. 6. 5. 4. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 stenosis. stenosis. - 2012;20:434 - Hip al. et BJ, Morris KA, McCullough CJ, Devin pain? JAMA pain? Neuroradiology, the requisites the Neuroradiology, DM. Yousem RI, Grossman Spine Am North Criteria et. al. J, Burns DF, Broderick ND, Patel 2015. Accessed on October 20, 2017. https://acsearch.acr.org/docs/69483/Narrative/ 2017. 20, on October Accessed 2015. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low about us tell examination physical and history the can DL. What Kent J, Rainville RA, Deyo - 358:818 Med 2008; Engl N J stenosis. spinal Lumbar practice. Clinical MB. Harris JN, Katz - 149(12):845 cost spondylolisthesis: degenerative without and with stenosis spinal of treatment Surgical al. et TD, Tosteson JD, Lurie ANA, Tosteson 2007. 8, November Seminar, Sg2 Web . Meeting Society Spine American North 2007 the from Highlights - pp.784   F surgeon surgicalfor planning, especially for multi who have f A CT/Myelogram lumbar spine (CPT    lumbar spinal stenosis if: contrast (CPT MRI lumbar spine without contrast (CPT or surgery criteria, see the following:

- CMM C requiring the frequent use of narcotic analgesics. Severe symptoms of neurogenic claudication restricting normal activity or Red Flag Indications ( (see F ailure of 6 week trial of provider MM- ® Lumbar Spinal Stenosis Spinal Lumbar 786. : Low Back Pain. American College of Radiology (ACR); Date of Origin: 1996. Last Review: Last 1996. Origin: of Date (ACR); Radiology of College American Pain. Back Low : 1.02002 Version SP- : 609: 608: . 1992; 268(6): 760- 268(6): 1992; . 853. ailed 6- 442. : : 1.1 Society, ® Lumbar Fusion (Arthrodesis) Lumbar Decompression 72131) General Considerations ); weeks of providerweeks of

Clinical guidelines for multidisciplinary spine care specialists: spinal specialists: care spine multidisciplinary for guidelines Clinical . 2006 20, November Accessed http://www.guideline.gov

is appropriate for those patients with clinical suspicion of see: 765. - SP effectiv - Expert Panel on Neurologic Imaging. ACR Appropriateness ACR Imaging. on Neurologic Panel Expert 1.2 - -

® Med Intern Ann years. 2 after eness directed treatment if requested by the operating directed treatment and clinical re - : : 72132) may also be considered patientsfor Red Flag Indications Red Flag , Surg Orthrop Acad Am J syndrome. spine ® 72148) or CT Lumbar Spine without or

, 2 - level lumbar spinal stenosis. nd

Ed. Philadelphia, Mosby, 2003, Mosby, Ed. Philadelphia, canbe asymptomatica or ); ); or

,2008 Dec; ,2008 www.eviCore.com evaluation

. Page 43of62 V2.0.2019 V2.0.2019 825.

back . It

Spine Imaging Imaging Guidelines V2.0.2019

SP-10: Sacro-Iliac (SI) Joint Pain, Inflammatory Spondylitis/Sacroiliitis and Fibromyalgia SP-10.1: Sacro-Iliac (SI) Joint Pain/Sacroiliitis 44 SP-10.2: Inflammatory Spondylitis 44 SP-10.3: Fibromyalgia 44

______© 2019 eviCore healthcare. All Rights Reserved. Page 44 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com    P  :SP-10.3  :SP-10.2   :SP-10.1 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 ractice Notes    investigational in adults. monitoring treatment effects using serial MRI studies remains controversial and ankylosing spondylitis, the ability of MRI to predict erosive changes, and the value of in several studies. However, the ability MRI of to characterize inflammation M when visible onroutine plain x changes to patient management decisions in patients with proven SI joint disorders T therapeutic SI joint anesthetic/corticosteroid injections can have diagnostic value. individualscan of buttock and/or posterior thigh without neurologic signs or symptoms. Affected Sacroiliitis can present with pain localized to the SI joint or referred pain to the evaluation andtreatment of fibromyalgia. Advanced diagnostic imaging is not supported by the scientific  Initi See also:      (CPT Pelvis CT without contrast (CPT here is no evidence demonstrating that advanced diagnostic imaging substantiates

RI has shown inflammatory changes in the SI joints prior to visible x SP- Failure of 6 weeks of MRI Cervical Spine without contrast (CPT  I reports neck pain following any head/maxillofacial/neck injury. region. (CPT contrast (CPT M Pelvis CT without contrast (CPT pelvis MRI Suspicion of neoplastic, inflammatory, or infectious disease: juvenile idiopathic arthritis. MRI pelviswithout and with contrast as indicated for pediatric patients with    theAnyone of following: al plain x plain al nitial plain x plain nitial

RI without without RI ® 72195) is appropriate if: CT without contrast of the affected spinal region if MRI is contraindicated Preoperative See: Fractures of the sacrum or sacroiliac joint(s); or 1.1 Inflammatory Spondylitis Fibromyalgia Sacro ® MS 72195) : :

General Considerations General SP- - rays are equivocal or not diagnostic. - : : 15.1 without and with contrast (CPT - - 1.2 Iliac (SI) Joint Pain/Sacroiliitis and with contrast rays are equivocal or not diagnostic;

ten point to the SI joint as the pain source. Provocative and/or ® 72125) : Rheumatoid Arthritis and Inflammatory Arthritis Arthritis Inflammatory and Rheumatoid planning Red Flag Indications Red

provider if if a patient with documented ankylosing spondylitis

- rays. ® - 72192) or MRI pelvis without contrast or MRI without contrast of the affected spinal directed treatment and clinical re - ® 72192) ); ); or

; or

if MRI is contraindicated ® ®

7214 72197) or MRI pelvis without contrast 1) 1) and

and CT Cervical Spine without

evidencethe for

evaluation (See: www.eviCore.com - ray changes

Page 45of62 V2.0.2019 V2.0.2019 in early in

Spine Imaging 10. 9. 8. 7. 6. 5. 2. 1. R 4. 3. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 eferences pain? JAMA pain? back low about us tell examination physical and history the can DL. What Kent J, Rainville RA, Deyo Am N RadiolClin imaging. resonance onmagnetic emphasis with assessment imaging practical Current arthritis: idiopathic Juvenile PS. Babyn EY, Lee R, Restropo Appropriateness Criteria Appropriateness ACR Imaging. Musculoskeletal on Panel Expert al. et. FD, Beaman MJ, Kransdorf SA, Bernard approach. multimodality a arthritis: idiopathic juvenile of Imaging JL. Demertzis AJ, White G, Khanna EF, Sheybani - 2007;56(12):4005 spondylitis. ankylosing with patients in inflammation joint and sacroiliac spinal both reduces significantly Adalimumab al. et RD, P, Inman Rahman D, Salonen RGW, Lambert Rheumatology - multiple A imaging. resonance by magnetic joints sacroiliac Scoring al. et X, Baraliakos DMFM, Heijde Der Van KGA, Hermann RBM, Landewe Surg, Orthop Acad Am . pain joint Sacroiliac al. et A, Cole SJ, P, Dreyer Dreyfuss - 2004;43:234 Rheumatology findings. laboratory and clinical to correlated Abnormalities spondylarthropathy. seronegative early Schiottz AG, Jurik KB, Puhakka https://acsearch.acr.org/docs/3094107/Narrative/ 2017. 20, onOctober Accessed 2016. Origin: of Date (ACR); Radiology of College Spine, Spine, trauma. coccygeal and BMI of role coccydynia: common of mechanisms and Causes G. Chatellier L, Doursounian JY, Maigne Spine, mobility. normal and hypermobility, luxation, differentiating elements Clinical position. sitting the in observed lesions the of and characteristics coccygodynia common of study the for protocol radiologic Standardized B. Tamalet and JY Maigne . 1992; 268(6): 760- 268(6): 1992; . , 2005;32:10. , 4014. ® Radiographics : Chronic Back Pain: Suspected Sacroiliitis/Spondyloarthropathy. Am Sacroiliitis/Spondyloarthropathy. Suspected Pain: Back Chronic : 237. - Christens 765.

- 2000;25:3072 - 253 2013;33(5):1 , en B, et al. Magnetic resonance imaging of sacroiliitis in sacroiliitis of imaging resonance Magnetic al. et B, en The Journal of Journal The experiment. reliability reader . 3079.

- 21:2588 1996; 1273. - 2013;51:703 , 2593. , & Rheumatism Arthritis 719. - 2004;12:255 www.eviCore.com

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Spine Imaging Imaging Guidelines V2.0.2019

SP-11: Pathological Spinal Compression Fractures SP-11.1: Pathological Spinal Compression Fractures 47

______© 2019 eviCore healthcare. All Rights Reserved. Page 47 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 6. 5. 4. 3. 2. 1. References an incidental finding on plain x presentation of insufficiency/low energy spinal compression fractures and can often be disease and infection. Sudden localized back pain, with or without trauma, is a typical the setting of other bone disease and medical conditions, in addition to neoplastic mineral density is the primary etiology of structural integrity withstand to physiologic loads and minor spinal trauma. Low bone Insufficiency/low energy spinal compression fractures of the spine occur due to the lack P   :SP-11.1 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 ractice Notes pain? JAMA pain? back low about us tell examination physical and history the can DL. What Kent J, Rainville Deyo RA, Physician Fam Am Fractures. Compression Vertebral of Management and A. Diagnosis Davis J, McCarthy Practice S, Brunton 116. - 69:111 2004; , Physician Fam Am elderly. in the fractures compression Vertebral M. Calvert JL, Old Criteria Appropriateness ACR Imaging. Musculoskeletal and Radiology, Interventional Imaging, Neurologic on Panels Expert al. et. CE, Ray FJ, CT, Wippold McConnell Criteria Appropriateness ACR Imaging. on Neurologic Panel Expert al. et. J, Burns DF, Broderick ND, Patel 2015. Accessed on October 20, 2017. https://acsearch.acr.org/docs/69483/Narrative/ 2017. 20, on October Accessed 2015. For surgery criteria, see- CMM    concordant with the spinal x considered after plain x MRI without contrast or CT without contrast of the affected spinal region can be   2013. Accessed on October 20, 2017. https://acsearch.acr.org/docs/70545/Narrative/ 2017. 20, on October Accessed 2013. (ACR) Radiology of College American Fractures. Compression

The acuity of the spinal compression fracture deformity onplain x week in apatient already predisposed to low energy/insufficiency fractures; or X- X- See surgical procedures; or individuals who are candidates for kyphoplasty, vertebroplasty or other spine Surgicalplanning following indeterminate, rays are non- rays reveal anew spinal compression fracture; or ® , 2005 Sept (Supplement): 781- (Supplement): Sept 2005 , : Low Back Pain. Back Low : Pathological Spinal Compression Fractures Compression Spinal Pathological , 2016; 94: 44- 94: 2016; , SP-

J Fam J care. in primary fractures compression Vertebral al. et D, Gold B, Carmichael . 1992; 268(6): 760- 268(6): 1992; . 1.2 : : Red Flag Indications Flag Red or diagnosticandsevere spinal pain persists more for than one 50.

Am - ray evaluation : 1996. Last Review: Last 1996. : Origin of Date (ACR); Radiology of College erican

765. - rays andcan be asymptomatic. - rays any for one of the following: : 607: known insufficiency spinal compression fractures in 788.

for mostfor of these fractures but could also occur in Primary

and

the location of the patient’s spinal pain is Vertebral Augmentation ; Date of Origin: 2010. Last Review: Last 2010. Origin: of Date ;

® : Management of Vertebral of Management :

- www.eviCore.com ray is is ray

. . Page 48of62 V2.0.2019 V2.0.2019

Spine Imaging   400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019  F - ONC For guidelines regarding advanced diagnostic imaging in this clinical setting, S or metastatic disease of the spine without neurological signs or symptoms:

kidneyand prostate. metastatic neoplastic disease, especially cancer of the breast, lung, thyroid, imaging guidelines in patients with spinal pain with ahistory of primary or S ee: 31. SP- - ONC 6: 6: . CordSpinal Compression : 12: 31.5 : : Spinal Pain in Cancer Patients Bone Bone

in c luding Vertebral Metastases for advanced diagnostic www.eviCore.com

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Spine Imaging Imaging Guidelines V2.0.2019

SP-13: Spinal Canal/Cord Disorders (e.g. Syringomyelia) SP-13.1: Initial Imaging Pathway 50 SP-13.2: Follow-up imaging 50

______© 2019 eviCore healthcare. All Rights Reserved. Page 50 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 1.  :SP-13.2   :SP-13.1 Reference the adultyears. Syringomyelia may begin to form in childhood but rarely becomes symptomatic before Practice Notes 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 - 870 pp: 2005, Lippincott, . In Rowland LP (ED.). LP (ED.). Rowland In . Syringomyelia ER, Mancall    involved. (CPT MRI cervical spine without contrast (CPT   O is syringomyelia MRI cervical spine without and with contrast (CPT    

nce a syrinx is identified by the initial MRI cervical spine without and with contrast: MRI of the thoracic spine without and with contrast (CPT syringobulbia; lower most extent of the syrinx or to identify askip lesion. Annual imaging until non- I unless tethered cord is suspected. Advanced diagnostic imaging of the lumbar spine is generally not indicated M contrast. traumatic syrinx is not appropriate without evidence of neurological deterioration. Repeat advanced diagnostic imaging in spinal cord injury patients with post neurologic deterioration. Repeatadvanced diagnos non- Advanced diagnostic imaging every three years lifefor can be performed once Following surgical treatment (including posterior fossa decompression). f there is aconcern for malignancy, imaging can be performed without RI of the brain, usuallywithout contrast (CPT ® 70551) and/or MRI thoracic spine without contrast (CPT Initial Imaging Pathway Imaging Initial Follow progression of the syringomyelia is established.

up imaging -up suspected. and 874. progressionthe of

tic imaging is appropriate when there is evidence of

® Merritt’s Neurology Merritt’s 72141) and MRI brain without contrast syringomyelia is established. ® ® 72156) is appropriate when 70551) to evaluate for

. 11 ®

th 72157)

Ed. Philadelphia, Ed. ® 72146) when

to define the www.eviCore.com

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and with

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Spine Imaging Imaging Guidelines V2.0.2019

SP-14: Spinal Deformities (e.g. Scoliosis/Kyphosis) SP-14.1: Spinal Deformities (e.g., Scoliosis/Kyphosis) 52 SP-14.2: Revision Spinal Deformity Surgery 52

______© 2019 eviCore healthcare. All Rights Reserved. Page 52 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 7. 6. 5. 1. References spinal deformity (e.g. disorders (e.g., posttraumatic paralysis) or degenerative spondylosis. Sagittal plane throughout life. If scoliosis begins in adulthood, it is usually secondary to neurologic spine. Scoliosis initially occurs in the pediatric and adolescent population and persists involve any or all levels of the spine but generally involves the thoracic and/or lumbar Scoliosis is defined as a curvature of the spine in the coronal plane. Scoliosis can Practice Notes  :SP-14.2    :SP-14.1 2. 4. 3. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Orthop Surg, Orthop Acad Am J reconstruction. in definitive Challenges injuries: war Extremity JR. Ficke AN, Pollak 2009. Surgeons; Orthopaedic review orthopaedic comprehensive AAOS JR. Lieberman Rao, RD, Smuck M. Orthopaedic Knowledge Update 4: Spine 4: Update Knowledge Orthopaedic M. Smuck RD, Rao, Nelson Textbook of Pediatrics of Textbook Nelson (Eds.). al. et HB, Jenson RE, Behrman RM, Kliegman In Scoliosis Congenital and Scoliosis Idiopathic Adolescent Kyphoscoliosis: SR. Boas Jenson HB, et al. (Eds.). (Eds.). al. et HB, Jenson DormansJP. HS, Hosalkar DA, Spiegel - pp.1843 2007, Elsevier, Philadelphia, - 2002;84:2230 Am, Surg Joint Bone J scoliosis. idiopathic infantile axis neural of Prevalence al. et DA, Szymanski LG, Lenke MB, Dobbs Am, Surg Joint Bone J scoliosis. idiopathic adolescent in imaging resonance magnetic preoperative routine of value Clinical al. S, et Burke C, Fras T, Do - pp.2811   preoperative If requested by the operating surgeon, the following studies can be performed for spinal surgery surgical for correction of spinal deformities. C a complex osseous deformity for preoperative evaluation. CT of the affected spinal regions (contrastas requested)     regions: isappropriate after plainx MRI without contrast or MRI without and with contrast of the affected spinal regions

TA TA or MRA is not medically necessary for preoperative planning for initial anterior MRA pelvis (CPT pelvis MRA C left thoracic curve with underlying spinal canal/cord pathology. Scoliosis with aconvex thoracic left curve due to a high association of aconvex on physical examination; or scoliosis For cases of syringomyelia, diastematomyelia, or tumors; or associated with spinal canal/cord pathology as such tethered cord, For cases of congenital scoliosis and other atypical curves that may be F or preoperative evaluation; or TA pelvis (CPT pelvis TA 2815. Revision Spinal Deformity Surgery Deformity Spinal Revision (e.g. Deformities Spinal

- 2008;16(11):407 planning for revision anterior spinal surgery: , , kyphosis, hyperlordosis) may be associated with scoliosis. ® ® Nelson Textbook of Pediatrics of Textbook Nelson 72191) and/or CTA abdomen (CPT 72198) and/or MRA abdomen (CPT when there are associated neurologic signs andsymptoms 417 - rays (e.g. rays

1844. (Chapter 678). In Kliegman RM, Behrman RE, Behrman RM, Kliegman In 678). (Chapter Spine The , , , , Cobb radiographs) of the affected spinal Scoliosis/Kyphosis) - 2001;83:577 . 18 . n Academy of n Academy America IL.: Rosemont, . th

7, 200 Elsevier, Philadelphia, Ed.

- 41:477 AAOS, , 2234. 579. ® is appropriate in cases with ®

74175); abnormalities in patients with patients in abnormalities 74185)

478

or www.eviCore.com (Chapter 416.5). (Chapter

. 18 . Page 53of62 V2.0.2019 V2.0.2019 th

Ed.

Spine Imaging 10. 11. 9. 12. 8. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 - 2006;14(5):101 Surg, Orthop Acad Am J Shoulder. the of Contracture Capsular Posterior BA. Goldberg HG, Bach Hedequist, D., Emans, J. Congenital scoliosis. Congenital J. Emans, D., Hedequist, Clin Orthop Relat Res Relat Orthop Clin relevance. clinical low and exposure radiation High access: spine lumbar anterior for angiography CT al. et J., Petersen B, Godny M, Gstottner Surgery. Joint and Bone of Journal The MF. Swiontkowski - 2010;30:1823 Radiographics Know. Should Radiologists What Imaging: Scoliosis al. et ES, Moon HS, Kim H, Kim 1842. 112.

J Am Acad Orthop Surg Orthop Acad Am J

- 1993:75A(9):1308 , JBJS - 2011;469(3):819 , – 2004;12:266 . www.eviCore.com 1317.

275 824. Page 54of62 . V2.0.2019 V2.0.2019 ,

Spine Imaging Imaging Guidelines V2.0.2019

SP-15: Post-Operative Spinal Disorders SP-15.1: Greater than Six Months Post-Operative 55 SP-15.2: Routine Post-Fusion Imaging 55 SP-15.3: Prolonged Intractable Pain Following Spinal Surgery Within Six Months 55 SP-15.4: Revision Fusion Surgery 56

______© 2019 eviCore healthcare. All Rights Reserved. Page 55 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com   Laminectomy: and/or Discectomy Open or without with fusions Spinal  laminectomy: and discectomy Open Months Six :SP-15.3   :SP-15.2  :SP-15.1 Anatomic Guidelines * 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Following plain x       F imaging study. Requests will beforwarded to Medical Director Review. T  new M forwarded to Medical Director Review. unsuccessful spine surgery ( P successful spinal fusion, advanced diagnostic imaging is generally not indicated. Requests will beforwarded to Medical Director Review. Following aclinically    affected spinal region(s) is appropriate when: MRI without and with contrast or surgery criteria, s hese can be challenging problems that may require more than one advanced ET ET

RI without and with contrast of the affected spinal region(s) if there are residual, - CMM - CMM - CMM - CMM - CMM C C S provider No significant improvement after a recent (within 3 months) six week trial of P , , ee atient is more than six months post MM- T/Myelography t of is not currently indicated thefor routine assessment of spinal fusions or recurrent Pain Following Spinal Surgery Spinal Following Pain Intractable Prolonged Post Routine Post Months Six than Greater SP- : 609: 608: 606: 605: 604: 601:

- 1.2 directed treatment with clinical re-

- , or worsening, or Lumbar Fusion (Arthrodesis) Decomp Lumbar Lumbar Microdiscectomy Cervical Microdiscectomy Posterior Cervical Decompression with or without Fusion Anterior Cervical Discectomy and Fusion rays of the affected spinal regions post : :

Red Flag Indications Flag Red . eethe following: he affected spinal region(s) MRI if is contraindicated. Imaging -Fusion see:

symptoms related to the surgical site. , MRI without contrast, ression SP- 2.10 - operative; : : Spine PET

-Operative evaluation; and or or - ). Requests for PET will be surgical, surgical, CT withou CT or

S ee t contrast SP www.eviCore.com -

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Within Within V2.0.2019 V2.0.2019 : of the

Spine Imaging 5. 4. 3. 2. References  1.  :SP-15.4 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 radiation exposure and low clinical releva clinical low and exposure radiation high access: spine lumbar anterior for angiography CT al. et J., Petersen B, Godny M, Gstottner - 2014;22:653 , Surg Orthop Acad Am J fractures. compression vertebral osteoporotic of treatment the for kyphoplasty and Vertebroplasty PA. Anderson GD, Schroeder JW, Savage 347. Kathuria S. Post S. Kathuria - 2012;50:731 Am, North Clin Thakkar RS, Malloy JP, Thakkar SC Thakkar JP, Malloy RS, Thakkar complications after spinal surgery and instrumentation. AJR instrumentation. and surgery spinal after complications Hayashi D, Roemer FW, Mian A, Gharaibeh M, et al. Imaging features of post of features Imaging al. et M, Gharaibeh Mian A, FW, Roemer D, Hayashi    For surgery criteria, see the following:   arthrodesis. preoperative If requested by the operating surgeon, the following studies can be performed for

- CMM - CMM C (CPT pelvis MRA C MM- TA Revision Fusion Surgery Fusion Revision

pelvis (CPT pelvis : 609: 604: 601: planning prior to surgical revision of a lumbar anterior spinal - Neuroimaging Clin N Am N Clin Neuroimaging imaging. spine augmentation vertebral Lumbar Fusion (Arthrodesis) Posterior Cervical Decompression with or without Anterior Cervical Discectomy and Fusion ® ® 72191) and/or CTA abdomen (CPT 72198) and/or MRA abdomen (CPT 747. , Carrino JA, Khanna AJ. Imaging the post the AJ. Imaging Khanna , JA, Carrino Clin Orthop Relat Res Relat Orthop Clin nce.

- 2012;199:W123 . ® - 2011;469(3):819 , ® 74175); 74185)

Fusion - W129. operative - or operative spine. Rad spine. operative - 2014;24(2):337 , www.eviCore.com 664.

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Spine Imaging Imaging Guidelines V2.0.2019

SP-16: Other Imaging Studies and Procedures Related to the Spine Imaging Guidelines SP-16.1: Prior to Spine Surgery 58 SP-16.2: Prior to Interventional Spinal Injections 58 SP-16.3: Prior to Spinal Cord Stimulator (SCS) Placement/Removal 59 SP-16.4: Following Vertebral Augmentation Procedures 59

______© 2019 eviCore healthcare. All Rights Reserved. Page 58 of 62 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com     :SP-16.2    :SP-16.1 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 Imaging Guidelines. advanced imaging studies of the spine are met as otherwise stated in the Spine lumbar spine interlaminar or caudal epidural steroid injections unless the criteria for A Imaging Guidelines. advanced imaging studies of the spine are met as otherwise stated in the Spine tran A Guidelines. imaging studies of the spine are met as otherwise stated in the Spine Imaging injections of the cervical and/or thoracic spine indicated within 12 months prior to interlaminar or transforaminal epidural steroid A Imaging Guidelines. advanced injections, medial branch blocks or radiofrequency ablations unless the criteria for Advanced diagnostic imaging studies of the spine are not required prior to facet joint       F Requests will beforwarded to Medical Director Review. spinal surgery unless abnormal vasculature is known or reasonably anticipated. M Spine met as otherwise stated in the Spine Imaging Guidelines. (See: SP prior to spine surgery when the criteria for advanced imaging studies of the spine are MRI or surgery criteria, s criteria, surgery or dvanced diagnostic imaging studies of the lumbar spine are not required prior to dvanced diagnostic imaging studies of the lumbar spine are indicated prior to dvanced diagnostic imaging studies of the cervical spine and/or thoracic spine are

RA andCTA are generally not indicated for - CMM - CMM - CMM - CMM - CMM C sforaminal epidural steroid injections of the lumbar spine when the criteria for / CT MM- , SP Prior to Interventional Spinal Injections Injections Spinal Interventional to Prior to Prior

should be performed within the past six (6) months for preoperative planning 609: Lumbar Fusion (Arthrodesis) 608: Lumbar Decompression 606: Lumbar Microdiscectomy 605: Cervical Microdiscectomy 604: Posterior Cervical Decompression with or without Fusion 601: - imaging studies of the spine are met as otherwise stated in the Spine 2.3: CT of the Spine 2.3: Anterior Cervical Discectomy and Fusion Spine Surgery Spine eethe following: , SP-

2.4: CT/Myelography 2.4: preoperative whenthecriteria for advanced planning of initial anterior ) - 2.2: MRI of the of MRI 2.2: www.eviCore.com

Page 59of62 V2.0.2019 V2.0.2019

Spine Imaging necessarywith each spinal injection or series of spinal injections. picture or intervening surgery. Repeat advanced diagnostic imaging studies are not recent scientific evidence- MRI has not been shown to change the outcome of interventional pain procedures in Practice Note   :SP-16.4     :SP-16.3    400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019  F evaluate neurologic sequelae resulting from cement extravasation. CT without contrast of the affected spinal region(s) within 24hours post  For interventional pain criteria, s placement will beforwarded to Medical Director Review. R stimulators. I CT/Myelography thoracic spine (CPT prior to SCS placement. CT thoracic spine without contrast (CPT MRI thoracic spine without c    F See  F   met: interlaminar or caudal epidural steroid injection when ALL of the following criteria are within the past twelve (12) months is required for aninitial trial of atransforaminal, w maging of the lumbar spine is not indicated for placem or surgery criteria, s or interventional pain criteria, s or anindividual with evidence of symptomatic spinal stenosis,

ithout myelography demonstrating severe spinal stenosis at the level to betreated equests for advanced diagnostic imaging of the cervical spine prior to SCS C - CMM - CMM - CMM C and/or muscle relaxants). physical methods including physical therapy and/or chiropractic care, NSAIDS Failureleastof at f age Signi Diagnostic evaluation has ruled out other potential causes of pain SP- MM- MM- - Following Vertebral Augmentation Procedures Augmentation Vertebral Following Prior to appropriate activities of daily living (ADLs) ficant functional limitations resulting in diminished quality of life and impaired 1.2 607: Primary Vertebral Augmentation 211: Spinal Cord Stimul 208: Radiofrequency Joint Ablation/Denervation 201: Facet Joint Injections 200: Epidural Steroid Injection : : Red Flag Indications Flag Red

Spinal Cord Stimulator (SCS) Cord Stimulator Spinal eethe following our (4) weeks of conservative treatment (e.g., exercise, based studies and without substantial change in the clinical ontrast (CPT ontrast

ee the following: ee the following: ators

for severe radicular pain ® 72129) are acceptable alternatives. ® 72146) is generally the study of choice

ent nor removal nor ent Placement

MRI or CT withor MRI CT or ®

72128) or /Removal www.eviCore.com

of spinalof cord

- procedure to Page 60of62 V2.0.2019 V2.0.2019

Spine Imaging 9. 8. 7. 6. 5. 2. 1. Reference 4. 3. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 (800) 918-8924 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging © 2019 eviCore healthcare. All Rights Reserved. Reserved. AllRights healthcare. eviCore © 2019 – 37:537 2017; RadioGraphics. Spine. Lumbar and Cervical the of Injections Epidural Guided al. Fluoroscopically LeeE, et JW, E, Lee Shim 237. - 5:230 2013; Rehabilitation. and Medicine Physical of Academy American injection. corticosteroid Cohen SP, Maus T. Point/Counterpoint T. Maus SP, Cohen 2015 JAMA injections. steroid epidural of safety the Improving JP. Rathmell MA, Huntoon HT, Benzon - 2012;172:134 injections. steroid epidural for referred radiculopathy lumbosacral with patients in making decision or results ontreatment MRI of Effect al. et SA, Strassels A, Gupta SP, Cohen pain? sciatica for injection steroid epidural lumbar to prior required be spine lumbar the of MRI routine Should NN. Knezevic KD, Candido A, Lissounov RF, Ghaly https://www.spine.org/PolicyPractice/CoverageRecommendations/AboutCoverageRecommendations dations. Recommen Coverage About Positions. Coverage Appropriate Defining Injections: Epidural Lumbar Committee. Coverage (NASS) Society Spine American North doi:10.1001/archinternmed.2011.593. 2012;172(2):134. Injections. Steroid Epidural for Referred Radiculopathy Lumbosacral With Patients in Making Decision or Results onTreatment MRI of Effect SP. Cohen treatment of lumbar radicular pain. pain. radicular lumbar of treatment the for steroids of injection Transforaminal of efficacy The N. Bogduk R, A, Ferch Ghahreman doi:10.1097/aln.0000000000000614. Injections. Steroid Epidural after Complications Neurologic Prevent to Safeguards al. et P, Dreyfuss HT, Benzon JP, Rathmell 2017. 1, August Accessed aspx.

; - 313:1713 s s 142. 1714. Anesthesiology Pain Medicine Pain 561. - The need for magnetic resonance imaging before epidual before imaging resonance magnetic for need The - 2015;122(5):974 . - 2010;11:1149 , . Medicine Internal of Archives 984. 1168. uro lInt uro Ne Surg Arch Intern Med, Intern Arch , 2015;6:48. , www.eviCore.com

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Spine Imaging Imaging Guidelines V2.0.2019

SP-17: Nuclear Medicine  Nuclear Medicine  Nuclear medicine studies are rarely used in the evaluation of the spine, but are indicated in the following circumstances:  Bone scan (CPT® 78315 or CPT® 78320) is indicated for evaluation of suspected loosening of orthopedic implants when recent plain x-ray is nondiagnostic.  Bone scan SPECT (CPT® 78320) or SPECT/CT (CPT® 78320) can be used if there is back pain with suspected failed fusion surgery with suspected painful pseudoarthrosis and MRI/CT are nondiagnostic.  Any of the following studies are indicated for initial evaluation of suspected osteomyelitis:  Bone scan (one of CPT® codes:78300, 78305, 78306, or 78315)  Nuclear Bone Marrow imaging (one of CPT® codes: 78102, 78103, or 78104)  Radiopharmaceutical inflammatory imaging (one of CPT® codes: 78805, 78806, or 78807)  For follow-up imaging, any of the following studies are indicated for evaluation of response to treatment in established osteomyelitis. The appropriate follow-up advanced imaging time frame will depend on the nature of the underlying disease and prior imaging. Follow-up advanced imaging requests will be forwarded for medical director review:  Bone scan (one of CPT® codes: 78300, 78305, 78306, or 78315)  Nuclear Bone Marrow imaging (one of CPT® codes: 78102, 78103, or 78104)  Radiopharmaceutical inflammatory imaging (one of CPT® codes: 78805, 78806, or 78807)SPECT bone scan (CPT® 78320) is indicated for evaluation of facet arthropathy in patients with ankylosing spondylitis, osteoarthritis, or rheumatoid arthritis.  SPECT bone scan (CPT® 78320) or SPECT/CT (CPT®78320) (if requested) is indicated for the evaluation of back pain and suspected spondylolysis.  SPECT has been described to identify spinal pain generators, pseudoarthrosis of spinal fusion or hardware failure when conventional advanced diagnostic imaging studies are inconclusive, non-diagnostic or equivocal. Requests for SPECT for these indications will be reviewed on a case-by-case basis by the Medical Director.

Reference 1. Patel ND, Broderick DF, Burns J, et. al. Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria®: Low Back Pain. American College of Radiology (ACR); Date of Origin: 1996. Last Review: 2015. Accessed on October 20, 2017. https://acsearch.acr.org/docs/69483/Narrative/.