BlueCross and BlueShield of Montana Medical Policy/Codes
Non-Operative Spinal Ultrasound
Chapter: Radiology
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: August 26, 2013
Description

Ultrasound is defined as “a radiologic technique in which deep structures of the body are visualized by recording the reflections (echoes) of ultrasonic waves directed into the tissues. The basic principle of ultrasonography is the same as that of depth-sounding in oceanographic studies of the ocean floor. The ultrasonic waves are confined to a narrow beam that may be transmitted through or refracted, absorbed, or reflected by the medium toward which they are directed, depending on the nature of the surface they strike. In diagnostic ultrasonography the ultrasonic waves are produced by electrically stimulating a crystal called a transducer. As the beam strikes an interface or boundary between tissues of varying density (e.g., muscle and blood) some of the sound waves are reflected back to the transducer as echoes. The echoes are then converted into electrical impulses that are displayed on an oscilloscope, presenting a “picture” of the tissues under examination.” (1)

Ultrasound has diagnostic benefits, including high resolution, real time assessment, no ionizing radiation, and is safe for all patients with no contraindications. A few of the many indications for ultrasonography include the evaluation of soft tissue pathology, as well as the detection of fluid collection and for visualization of cartilage and bone surfaces. (2)

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.

Medically Necessary

Blue Cross and Blue Shield of Montana (BCBSMT) may consider non-operative diagnostic spinal ultrasound medically necessary to evaluate congenital anomalies of the spine and spinal cord (e.g., spinal bifida, spinal dysraphism) in newborns and infants two years of age or younger.

Investigational

BCBSMT considers non-operative diagnostic spinal ultrasound experimental, investigational and unproven for any other indication, including but not limited to evaluation of:

  • Back pain or radicular symptoms (e.g., disk herniation, spinal stenosis, nerve root pathology);
  • Inflammation;
  • Congenital anomalies for individual over the age of two years

Rationale

In 1998 Nazarian and colleagues performed sonographic studies that evaluated the ability of paraspinal ultrasonography to identify abnormal echogenicity in patients with cervical or lumbar back pain, or both. Paraspinal ultrasonography was performed on 82 subjects, including 23 asymptomatic controls. Echogenicity in the region of nerve roots and facets was assessed. Readings were correlated with location of patients' symptoms, if any. Receiver operating characteristic analysis demonstrated that evaluation of nerve roots by all four readers did not differ significantly from chance (0.07 < P < 0.99). Specificities ranged from 0 to 0.68. Kappa values were 0.06 for cervical and -0.06 for lumbar spine. Ultrasonography was unable to demonstrate abnormal echogenicity adjacent to facets in symptomatic patients. The authors concluded that paraspinal ultrasonography is neither accurate nor reproducible in evaluating patients with cervical and lumbar back pain. (3)

Hughes et al. conducted at study to evaluate the role of spinal ultrasound in detecting occult spinal dysraphism (OSD) in neonates and infants, and to determine the degree of agreement between ultrasound and magnetic resonance imaging (MRI) findings. Eighty-five consecutive infants had spinal ultrasound over 31 months. Of these, 15 patients (age 1 day-7 months, mean 40 days; nine male) had follow-up MRI. Ultrasound and MRI findings were correlated retrospectively. Six out of 15 (40%) ultrasound examinations showed full agreement with MRI, seven of 15 (47%) had partial agreement, and two of 15 (13%) had no agreement. In the present series ultrasound failed to visualize: four of four dorsal dermal sinuses, three of four fatty filum terminales, one of one terminal lipoma, two of four partial sacral agenesis, three of four hydromyelia and one of 10 low-lying cords. The authors concluded that agreement between ultrasound and MRI was good, particularly for the detection of low-lying cord (90%), and therefore they recommend ultrasound as a first-line screening test for OSD. If ultrasound is abnormal, equivocal or technically limited, MRI is advised for full assessment. (4)

Chou et al. published a joint clinical practice guideline on the diagnosis and treatment of low back pain from the American College of Physicians and the American Pain Society. Their guideline made 7 recommendations, including the following: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Their guidelines do not make any recommendation for use of ultrasound. (5)

In 1998, the American Academy of Neurology's (AAN) Therapeutics and Technology Assessment Subcommittee developed a statement on spinal ultrasound in response to numerous inquiries from neurologists questioning the utility of spinal ultrasound in evaluating back pain and radicular disorders. After conducting a literature search and collecting expert opinion, the AAN concluded that it could not recommend ultrasound for use in the clinical evaluation of such patients. As part of the AAN’s 1998 research and included in the AAN’s 1998 document, the American College of Radiology (ACR) submitted the following adopted statement on spinal ultrasound: “Over the past several years interest has developed in the use of ultrasound technology for the evaluation of the spine and paraspinal regions in adults. While diagnostic ultrasound is appropriately used intra-operatively; in the newborn and infants for the evaluation of the spinal cord and canal, and for multiple musculoskeletal applications in adults, there is currently no documented scientific evidence of the efficacy of this modality in the evaluation of the paraspinal tissues and the spine in adults.” The ANN concluded that no published peer-reviewed literature supports the use of diagnostic ultrasound in the evaluation of patients with back pain or radicular symptoms. The procedure cannot be recommended for use in the clinical evaluation of such patients. (6)

The American Chiropractic Association (ACA) ratified their policy, titled “Diagnostic Ultrasound of the Adult Spine”, in May 1996 and this position has not been updated: “Diagnostic ultrasound has been shown to be a useful modality for evaluating certain musculoskeletal complaints. Fetal, pediatric and intra-operative applications have been published in the scientific literature. The quality of ultrasound images is extremely dependent on operator skill. The resolution abilities of the equipment may have an impact on diagnostic yield and accuracy. Consequently, the importance of training to establish technologic as well as interpretive competency cannot be understated. The application of diagnostic ultrasound in the adult spine in areas such as disc herniation, spinal stenosis and nerve root pathology is inadequately studied and its routine application for these purposes cannot be supported by the evidence at this time.” (7)

The American Institute of Ultrasound in Medicine (AIUM) Official Statement titled Nonoperative Spinal/Paraspinal Ultrasound in Adults (2002) states that there is insufficient evidence in the peer-reviewed medical literature establishing the value of non-operative spinal/paraspinal ultrasound in adults. Therefore, the AIUM states that, at this time, the use of non-operative spinal/paraspinal ultrasound in adults (for study of facet joints and capsules, nerve and fascial edema, and other subtle paraspinous abnormalities) for diagnostic evaluation, for evaluation of pain or radiculopathy syndromes, and for monitoring of therapy has no proven clinical utility. Nonoperative spinal/paraspinal ultrasound in adults should be considered investigational. (8)

Summary

There is evidence in published peer reviewed literature to support the use of spinal ultrasound for specific indications, including intraoperative spinal ultrasound. In addition, the use of ultrasound on newborns and infants is effective in diagnosing suspected occult and non-occult spinal dysraphism, spinal cord tumors, vascular malformations and birth-related trauma. There is insufficient evidence in the peer-reviewed medical literature establishing the value of nonoperative spinal/paraspinal diagnostic ultrasound in the adult spine in areas such as disc herniation, spinal stenosis and nerve root pathology  adults.

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
88.79, 720-724.9,  741.00, 741.01, 741.02, 741.03, 741.90, 741.91, 741.92, 741.93
ICD-10 Codes

A18.01, M08.1, M25.78, M43.20, M43.21, M43.22, M43.23, M43.24, M43.25, M43.26, M43.27, M43.28, M43.6, M43.8X9, M45.0, M45.1, M45.2, M45.3, M45.4, M45.5, M45.6, M45.7, M45.8, M45.9, M46.00, M46.01, M46.02, M46.03, M46.04, M46.05, M46.06, M46.07, M46.08, M46.09, M46.1, M46.40, M46.41, M46.42, M46.43, M46.44, M46.45, M46.46, M46.47, M46.48, M46.49, M46.50, M46.51, M46.52, M46.53, M46.54, M46.55, M46.56, M46.57, M46.58, M46.59, M46.80, M46.81, M46.82, M46.83, M46.84, M46.85, M46.86, M46.87, M46.88, M46.89, M46.90, M46.91, M46.92, M46.93, M46.94, M46.95, M46.96, M46.97, M46.98, M46.99, M47.011, M47.012, M47.013, M47.014, M47.015, M47.016, M47.019, M47.021, M47.022, M47.029, M47.10, M47.11, M47.12, M47.13, M47.14, M47.15, M47.16, M47.17, M47.18, M47.20, M47.21, M47.22, M47.23, M47.24, M47.25, M47.26, M47.27, M47.28, M47.811, M47.812, M47.813, M47.814, M47.815, M47.816, M47.817, M47.818, M47.819, M47.891, M47.892, M47.893, M47.894, M47.895, M47.896, M47.897, M47.898, M47.899, M47.9, M48.00, M48.01, M48.02, M48.03, M48.04, M48.05, M48.06, M48.07, M48.08, M48.10, M48.11, M48.12, M48.13, M48.14, M48.15, M48.16, M48.17, M48.18, M48.19, M48.20, M48.21, M48.22, M48.23, M48.24, M48.25, M48.26, M48.27, M48.30, M48.31, M48.32, M48.33, M48.34, M48.35, M48.36, M48.37, M48.38, M48.8X1, M48.8X2, M48.8X2, M48.8X3, M48.8X4, M48.8X5, M48.8X6, M48.8X7, M48.8X8, M48.8X9, M48.9, M49.80, M49.81, M49.82, M49.83, M49.84, M49.85, M49.86, M49.87, M49.88, M49.89, M50.00, M50.01, M50.02, M50.03, M50.10, M50.11, M50.12, M50.13, M50.20, M50.21, M50.22, M50.23, M50.30, M50.31, M50.32, M50.33, M50.80, M50.81, M50.82, M50.83, M50.90, M50.91, M50.92, M50.93, M51.04, M51.05, M51.06, M51.07, M51.14, M51.15, M51.16, M51.17, M51.24, M51.25, M51.26, M51.27, M51.34, M51.35, M51.36, M51.37, M51.44, M51.45, M51.46, M51.47, M51.84, M51.85, M51.86, M51.87, M51.9, M53.0, M53.1, M53.2X7, M53.2X8, M53.3, M53.80, M53.81, M53.82, M53.83, M53.84, M53.85, M53.86, M53.87, M53.88, M53.9, M54.00, M54.01, M54.02, M54.03, M54.04, M54.05, M54.06, M54.07, M54.08, M54.09, M54.11, M54.12, M54.13, M54.14, M54.15, M54.16, M54.17, M54.2, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M54.5, M54.6, M54.81, M54.89, M54.9, M62.830, M67.88, M96.1, M99.20, M99.21, M99.22, M99.23, M99.24, M99.25, M99.26, M99.27, M99.28, M99.29, M99.30, M99.31, M99.32, M99.33, M99.34, M99.35, M99.36, M99.37, M99.38, M99.39, M99.40, M99.41, M99.42, M99.43, M99.44, M99.45, M99.46, M99.47, M99.48, M99.49, M99.50, M99.51, M99.52, M99.53, M99.54, M99.55, M99.56, M99.57, M99.58, M99.59, M99.60, M99.61, M99.62, M99.63, M99.64, M99.65, M99.66, M99.67, M99.68, M99.69, M99.70, M99.71, M99.72, M99.73, M99.74, M99.75, M99.76, M99.77, M99.78, M99.79, B04BZZZ, BR40ZZZ, BR49ZZZ, BR4FZZZ, BR47ZZZ

Procedural Codes: 76800
References
  1. The Free Dictionary by Farlex at   http://medical-dictionary.thefreedictionary.com (accessed 2012 December 3).
  2. Blankenstein A. Ultrasound in the diagnosis of clinical orthopedics: The orthopedic stethoscope. World J Orthop 2011 February 18; 2(2): 13-24.
  3. Nazarian, L.N., Zegel, H.G., et al. Paraspinal ultrasonography: lack of accuracy in evaluating patients with cervical or lumbar back pain. Journal of Ultrasonic Medicine 1998; 17(2): 117-22.
  4. Hughes, J.A., De Bruyn, R., et al. Evaluation of spinal ultrasound in spinal dysraphism. Clinical Radiology 2003 March; 58(3):227-33.
  5. Chou R, Qaseem A, Snow V. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2008 Feb 5; 148(3):247-8.
  6. Review of the literature on spinal ultrasound for the evaluation of back pain and radicular disorders. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology (1998) 51:343-44.
  7. Diagnostic ultrasound of the adult spine—ACA, Arlington, Virginia:  American Chiropractic Association. http://www.amerchiro.org (Accessed 2012 December 3).
  8. Nonoperative spinal/paraspinal ultrasound in adults—AIUM. Laurel, Maryland:  American Institute of Ultrasound Medicine 2009 April 6) Available at <www.aium.org> (accessed 2012 December 3).
  9. Non-operative spinal/paraspinal ultrasound in adults—Position statement. Reston, Virginia: The American College of Radiology (2005).
History
August 2013  New 2013 BCBSMT medical policy.
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Non-Operative Spinal Ultrasound