BlueCross and BlueShield of Montana Medical Policy/Codes
Dynamic Spinal Visualization
Chapter: Radiology
Current Effective Date: September 24, 2013
Original Effective Date: December 21, 2010
Publish Date: September 24, 2013
Revised Dates: September 7, 2012; November 12, 2012; August 27, 2013
Description

Dynamic spinal visualization is a general term addressing different imaging technologies, including digital motion x-ray and videofluoroscopy (also known as cineradiography) that allow the simultaneous visualization of movement of internal body structures such as the spine (vertebrae) with external body movement. These technologies have been proposed for the evaluation of spinal disorders including low back pain.

Background

Most spinal visualization methods use x-rays to create images either on film, video monitor, or computer screen. Digital motion x-ray involves the use of either film x-ray or computer-based x-ray ‘snapshots’ taken in sequence as a patient moves. Film x-rays are digitized into a computer for manipulation, while computer-based x-rays are automatically created in a digital format. Using a computer program, the digitized snapshots are then put in order and then played on a video monitor, creating a moving image of the inside of the body. This moving image can then be evaluated by a physician alone or by using a computer that evaluates several aspects of the body’s structure, such as intervertebral flexion and extension, to determine the presence or absence of abnormalities.

Videofluoroscopy and cineradiography are different names for the same procedure, which uses a technique called fluoroscopy to create real-time video images of internal structures of the body. Unlike standard x-rays, which take a single picture at one point in time, fluoroscopy provides motion pictures of the body. The results of these techniques can be displayed on a video monitor as the procedure is being conducted, as well as recorded, to allow computer analysis or evaluation at a later time. Like digital motion x-ray, the results can be evaluated by a physician alone or with the assistance of computer analysis software.

Dynamic magnetic resonance imaging (MRI) is also being developed for imaging of the cervical spine. This technique uses an MRI-compatible stepless motorized positioning device (NeuroSwing, Fresenius/Siemens) and a real-time true fast imaging with steady-state precession (FISP) sequence to provide passive kinematic imaging of the cervical spine. The quality of the images is lower than a typical MRI sequence, but is proposed to be adequate to observe changes in the alignment of vertebral bodies, the width of the spinal canal, and the spinal cord. Higher-resolution imaging can be performed at the end positions of flexion and extension.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Dynamic spinal visualization, including but not limited to digital motion x-ray of the spine, and including digitization of spinal x-rays and computerized analysis of the back or spine, is considered experimental, investigational and unproven for all indications.

Cineradiography and videofluoroscopy (VF, also called videofluorography), when used to visualize movement of the back or spine, is considered experimental, investigational and unproven for all indications.

Policy Guidelines

The American Medical Association recommends that digital motion x-ray, videofluoroscopy, and cineradiography should be reported using 76120 and 76125 and not unlisted codes.

At times, motion may be incorporated into a magnetic resonance imaging (MRI) study of the spine or a joint (e.g., the knee). When this occurs, it is considered part of the MRI study and would not be billed separately or in addition to the MRI study, and would not be reimbursed at a higher rate than the MRI.

Rationale

At the time this policy was created, the literature evaluating the clinical utility of dynamic spinal visualization techniques, including digital motion x-ray and cineradiography (videofluoroscopy) for the evaluation and assessment of the spine, was limited to a few studies involving small numbers of participants. (1-3) No evidence was identified to indicate that clinical use improves health outcomes. While there were reports of the correlation of this technique to disc degeneration, (4) no studies had evaluated the incremental value of this information compared to the standard evaluation. In addition, although some studies had shown that abnormalities in spinal motion are found in individuals with low back pain, particularly those with spondylolisthesis, the test did not always separate those with disease from those without disease. (5)

As of the most recent literature update through July 2012, the evidence on dynamic spinal visualization remains predominantly of comparisons of spine kinetics in patients with neck or back pain with healthy controls. For example, Teyhen et al. compared 20 patients with lower back pain to 20 healthy controls to provide construct validity for a clinical prediction rule that would identify patients likely to benefit from stabilization exercises, (6) while Ahmadi and colleagues used digital videofluoroscopy to compare 15 patients with lower back pain and 15 controls to assist in identifying better criteria for diagnosis of lumbar segmental instability. (7) Another study from 2009 used dynamic fluoroscopy to assess lateral flexion in 30 healthy controls, noting that data pooling from multiple studies would be needed to establish a complete database of reference limits from asymptomatic individuals. (8)

A feasibility study of dynamic magnetic resonance imaging (MRI) was reported in 2012. (9) This study used a prototype of the NeuroSwing positioning device and evaluated cervical spine kinematics in 32 patients who had previously undergone anterior cervical discectomy and fusion (ACDF). The quality of images was considered to be adequate, although there was some artifact from the titanium implants used in ACDF.

Summary

The evidence at this time is insufficient to evaluate the effect on health outcomes of digital motion x-rays, cineradiography/videofluoroscopy, or dynamic MRI of the spine for any indication.

2013 Update

A search of peer reviewed literature through June 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

A 2011 guideline from the American College of Occupational and Environmental Medicine states that for the assessment of acute, subacute, or chronic LBP, videofluoroscopy was “Not Recommended, Insufficient Evidence.” (10)

Coding

Disclaimer for coding information on Medical Policies          

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Experimental, investigational and unproven for all diagnoses.

ICD-10 Codes

Experimental, investigational and unproven for all diagnoses.

Procedural Codes: 76120, 76125
References
  1. Hino H, Abumi K, Kanayama M et al. Dynamic motion analysis of normal and unstable cervical spines using cineradiography. An in vivo study. Spine (Phila Pa 1976) 1999; 24(2):163-8.
  2. Takayanagi K, Takahashi K, Yamagata M et al. Using cineradiography for continuous dynamic-motion analysis of the lumbar spine. Spine (Phila Pa 1976) 2001; 26(17):1858-65.
  3. Wong KW, Leong JC, Chan MK et al. The flexion-extension profile of lumbar spine in 100 healthy volunteers. Spine (Phila Pa 1976) 2004; 29(15):1636-41.
  4. Fujiwara A, Tamai K, An HS et al. The relationship between disc degeneration, facet joint osteoarthritis, and stability of the degenerative lumbar spine. J Spinal Disord 2000; 13(5):444-50.
  5. Okawa A, Shinomiya K, Komori H et al. Dynamic motion study of the whole lumbar spine by videofluoroscopy. Spine (Phila Pa 1976) 1998; 23(16):1743-9.
  6. Teyhen DS, Flynn TW, Childs JD et al. Arthrokinematics in a subgroup of patients likely to benefit from a lumbar stabilization exercise program. Phys Ther 2007; 87(3):313-25.
  7. Ahmadi A, Maroufi N, Behtash H et al. Kinematic analysis of dynamic lumbar motion in patients with lumbar segmental instability using digital videofluoroscopy. Eur Spine J 2009; 18(11):1677-85.
  8. Mellor FE, Muggleton JM, Bagust J et al. Midlumbar lateral flexion stability measured in healthy volunteers by in vivo fluoroscopy. Spine (Phila Pa 1976) 2009; 34(22):E811-7.
  9. Gerigk L, Bostel T, Hegewald A et al. Dynamic magnetic resonance imaging of the cervical spine with high-resolution 3-dimensional T2-imaging. Clin Neuroradiol 2012; 22(1):93-9.
  10. ECRI Institute. Dynamic Spinal Visualization for Diagnosing Spinal Disorders. Plymouth Meeting (PA): ECRI Institute; 2013 Feb. 7 p. (Hotline Response).
  11. Dynamic Spinal Visualization. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (September 2012) Surgery 6.01.46.
History
September 2012 Policy updated with literature review through July 2011; no new references added; policy statement unchanged
November 2012 Policy updated with literature review through July 2012; reference 9 added; policy statement unchanged.
September 2013 Policy formatting and language revised.  Policy statement unchanged.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Dynamic Spinal Visualization