June 2, 2026
Four out of every five people experience back pain in their lifetime. In cases of acute, uncomplicated low back pain, immediate imaging usually isn’t helpful because most cases resolve on their own within the first few weeks, according to the American College of Radiology Appropriateness Criteria® Low Back Pain. The criteria instead recommend first managing symptoms with appropriate pain control and physical therapy.
To support appropriate care for our members, we track Use of Imaging Studies for Low Back Pain. This Healthcare Effectiveness Data and Information Set (HEDIS®) measure captures members:
- Who are ages 18 to 75 with a principal diagnosis of low back pain; and,
- Who did not have an imaging study − plain X-ray, MRI or CT scan − within 28 days of the diagnosis
Tips to consider
- If there aren’t indications of underlying conditions, consider avoiding ordering diagnostic studies in the first four weeks of new-onset back pain.
- Always check eligibility and benefits first through Availity® Essentials or your preferred vendor prior to rendering services. This step will confirm prior authorization requirements for advanced imaging and utilization management vendors, if applicable.
- Educate members about conservative treatment, normal healing times, self-care and home treatments. Home treatments may include heat or ice, staying active, stretching exercises and anti-inflammatories. We have information to share with members.
- Use complete and accurate codes, including correct exclusion codes when indicated. Members with preexisting back conditions in the last six months and certain conditions are excluded from this measure. Refer to our Quality Care 2026 booklet for codes for uncomplicated low back and common exclusions. You can access it in Availity Essentials within our Payer Spaces in the resources section.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to Blue Cross and Blue Shield of Montana. BCBSMT makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.
HEDIS is a registered trademark of the National Committee for Quality Assurance.
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material, is not a guarantee that the service or treatment is a covered benefit and members should refer to their member contract or member guide for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.