Medical Policy Computed Tomography (CT) Lumbar Computed...  Medical Policy Computed Tomography (CT)

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    Medical Policy Computed Tomography (CT) Lumbar Spine

    Table of Contents

    Policy: Commercial Policy History Information Pertaining to All Policies

    Authorization Information References

    Coding Information Endnotes

    Policy Number: 755 BCBSA Reference Number: N/A

    Related Policies Medicare Advantage: High-Technology Radiology and Sleep Disorder Management Clinical

    and Utilization Guidance Redirect, #923

    Cardiac Computed Tomography (CT) for Quantitative Evaluation of Coronary Calcification, #832

    Computed Tomography (CT) Chest, #752

    Computed Tomography (CT) Abdomen & Pelvis Combination, #750

    Computed Tomography (CT) Abdomen, #749

    Computed Tomography (CT) Cardiac (Structure), #833

    Computed Tomography (CT) Cervical Spine, #751

    Computed Tomography (CT) Head, #753

    Computed Tomography (CT) Lower Extremity, #754

    Computed Tomography (CT) Neck for Soft Tissue Evaluation, #756

    Computed Tomography (CT) Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, including Mastoids, #757

    Computed Tomography (CT) Paranasal Sinus & Maxillofacial Area, #758

    Computed Tomography (CT) Pelvis, #791

    Computed Tomography (CT) Thoracic Spine, #759

    Computed Tomography (CT) Upper Extremity, #760

    Computed Tomography (CT) CT Colonography (Virtual Colonoscopy), #179

    Policy1 Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

    ADULTS Computed Tomography (CT) Lumbar Spine is considered MEDICALLY NECESSARY for the following conditions: Abnormalities detected on other imaging studies which require additional clarification to direct treatment

    http://www.bluecrossma.com/common/en_US/medical_policies/923%20Medicare%20Advantage%20High%20Technology%20Radiology%20&%20Sleep%20Disorder%20Management%20Redirect%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/832%20Cardiac%20Computed%20Tomography%20(CT)%20for%20Quantitative%20Evaluation%20of%20Coronary%20Calcification%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/752%20Computed%20Tomography%20(CT)%20Chest%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/750%20Computed%20Tomography%20(CT)%20Abdomen%20and%20Pelvis%20Combination%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/749%20Computed%20Tomography%20(CT)%20Abdomen%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/833%20Computed%20Tomography%20(CT)%20Cardiac%20(Structure)%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/751%20Computed%20Tomography%20(CT)%20Cervical%20Spine%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/753%20Computed%20Tomography%20(CT)%20Head%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/754%20Computed%20Tomography%20(CT)%20Lower%20Extremity%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/756%20Computed%20Tomography%20(CT)%20Neck%20for%20Soft%20Tissue%20Evaluation%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/757%20Computed%20Tomography%20(CT)%20Orbit,%20Sella%20Turcica,%20Posterior%20Fossa,%20Temporal%20Bone,%20including%20Mastoids%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/758%20Computed%20Tomography%20(CT)%20Paranasal%20Sinus%20&%20Maxillofacial%20Area%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/791%20Computed%20Tomography%20(CT)%20Pelvis%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/759%20Computed%20Tomography%20(CT)%20Thoracic%20Spine%20prn.pdfhttp://blueweb.bluecrossma.com/root/resources/Medical_Policy_Administration/760%20Computed%20Tomography%20(CT)%20Upper%20Extremity%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/179%20Computed%20Tomography%20(CT)%20CT%20Colonography%20(Virtual%20Colonoscopy)%20prn.pdfhttps://www.bluecrossma.com/common/en_US/medical_policies/Definition%20of%20Med%20Nec%20Inv%20Not%20Med%20Nec%20prn.pdf#page=1

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    Fracture evaluation

    Following initial evaluation with radiographs Post-trauma

    Neurologic deficit with possible spinal cord injury

    Progressively worsening pain Post-myelogram CT or CT following other lumbar spine interventional procedure Spondylolysis and spondylolisthesis

    Following non-diagnostic or abnormal lumbar spine radiographs (including oblique views) which require additional clarification to direct treatment in an operative candidate

    When the patients condition meets the lumbar spine MRI guidelines, but there is either a contraindication to MRI or the patient cannot tolerate MRI examination (for example, due to claustrophobia) For most other indications, MRI is the preferred modality for advanced lumbar spine imaging, unless contraindicated Congenital spine anomalies

    Lumbar spine dysraphism and other congenital anomalies involving the lumbar spine and/or lower spinal cord (Conus Medullaris). filum terminale or nerve roots, when MRI is contraindicated

    Congenital vertebral defects for assessment of bony defects such as segmentation and fusion anomalies

    Infectious process

    Including but not limited to the following: o Abscess o Arachnoiditis o Discitis o Osteomyelitis

    Low back pain with signs of cauda equina compression1

    In a patient with low back or radicular pain and red flag signs including: o Severe bilateral sciatica, especially L5-S1 distribution o Saddle or genital sensory disturbance o Bladder, bowel or sexual dysfunction

    Note: The diagnosis of acute cord compression is often considered a medical emergency and typically not managed by elective outpatient imaging Low back pain with signs of radicular compression

    In a patient with low back or radicular pain and neurologic findings related to the lumbar spine such as:

    o Reflex abnormality o Objective muscle weakness o Objective sensory abnormality in the lumbar dermatome distribution o Spasticity

    Note: Imaging in patients with polyneuropathy without additional abnormalities on neurological exam is not indicated2-5 Non-specific low back pain

    In a patient where focused history and physical exam suggest non-specific lumbar pain and/or referred buttock or lower extremity pain and all of the following are met:

    o Patient is a potential candidate for surgery or epidural steroid injection; AND

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    o Patient has, following clinical examination, completed a minimum of six (6) consecutive weeks of physician supervised conservative therapy for the current episode of pain, including but not limited to any of the following:

    NSAIDs Muscle relaxants Steroids Physical therapy; AND

    o After trial of conservative therapy as listed above, patient fails to show substantial improvement on clinical reevaluation; OR

    Low back pain not meeting the above criteria but associated with red flag symptoms such as unexplained weight loss, history of malignant disease, fever, drug abuse, or tuberculosis, abnormal labs suggestive of malignancy such as abnormal serum or urine electrophoresis, elevated prostate specific antigen (PSA)

    Post-operative or post-procedure evaluation Preoperative or pre-procedure evaluation Note: This indication is for pre-operative evaluation of conditions not specifically referenced elsewhere in this policy. Severe scoliosis, including the following patient populations:

    With high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital scoliosis; OR

    With adolescent idiopathic scoliosis and atypical findings (pain, rapid progression, development of neurologic signs/symptoms); OR

    With scoliosis related to other pathologic processes, such as neurofibromatosis; OR

    For pre-operative evaluation of severe scoliosis Spondyloarthropathies Note: Including but not limited to: ankylosing spondylitis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with inflammatory bowel disease, juvenile-onset spondyloarthritis

    For diagnosis following non-diagnostic work-up including but not limited to: o Radiographs o Standard laboratory work-up for spondyloarthropathy

    Tethered cord Tumor evaluation

    Including but not limited to the following: o Primary or metastatic neoplasm involving the vertebrae o Tumor spread within the spinal canal o Spinal cord neoplasm

    PEDIATRICS Computed Tomography (CT) Lumbar Spine is considered MEDICALLY NECESSARY for the following conditions:

    Abnormality detected on other imaging study which requires additional clarification to direct treatment Cauda equina syndrome Contraindication to MRI

    Patient meets criteria for MRI exam (any one of the following)

    https://www.bluecrossma.com/common/en_US/medical_policies/Definition%20of%20Med%20Nec%20Inv%20Not%20Med%20Nec%20prn.pdf#page=1

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    o Patient has a contraindication to MRI (examples include metallic foreign bodies, permanent pacemaker, implantable cardioverter-defibrillators, and intracranial aneurysm surgical clips that are not compatible with MR imaging)

    o Patient is claustrophobic and unable to tolerate MRI Congenital spine anomaly (any one of the following)

    Achondroplasia and other dwarfism

    Congenital kyphosis and scoliosis

    Klippel-Feil syndrome

    Mucopolysaccharidosis

    Neurofibromatosis

    Other vertebral segmentation and fusion defects (hemi, block and butterfly vertebrae)

    Sclerosing bone dysplasia

    Skeletal dysplasia

    Spondyloepiphyseal dysplasia

    Syndromes including Do