Medical Policy



Subject: Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
Document #: RAD.00034 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description/Scope

This document addresses the use of dynamic spinal visualization, digital motion x-ray, cineradiography or videofluoroscopy, to produce moving images of the spine for the detection or evaluation of structural or functional abnormalities.

Position Statement

Investigational and Not Medically Necessary:

Dynamic spinal visualization, including, but not limited to, digital motion x-ray of the spine, with or without digitization of spinal x-rays and computerized analysis of the back or spine, is considered investigational and not medically necessary for all indications.

Dynamic spinal visualization, including, but not limited to, cineradiography, also known as videofluoroscopy, when used to visualize movement of the back or spine, is considered investigational and not medically necessary for all indications.

Rationale

The current literature evaluating the clinical utility of dynamic spinal visualization techniques, including but not limited to digital motion x-ray and cineradiography (videofluoroscopy), for the evaluation and assessment of the spine is limited to a few studies involving very small numbers of participants.  While these studies do indicate that there may be some benefit from the use of these technologies, further evidence from large controlled trials is needed to demonstrate that the results have significant impact on clinical care and are superior to currently available alternatives.  At this time, the data is insufficient to support the use of digital motion x-rays, or cineradiography/videofluoroscopy of the spine for any indication.

Background/Overview

Dynamic spinal visualization is a general term addressing the use of several different imaging technologies, including digital motion x-ray and cineradiography, which is also known as videofluoroscopy.  These technologies allow the simultaneous visualization of movement of internal body structures, such as the skeleton, intervertebral discs and ligaments, with corresponding external body movement.  All of these methods use x-rays to create images either on film, on a video monitor, or on a computer screen.  These technologies have been proposed for the evaluation of back pain.

Digital motion x-ray involves the use of either film x-ray or computer-based x-ray 'snapshots' taken in sequence as a person moves in front of an x-ray camera.  Film x-rays are digitized into a computer for manipulation while computer-based x-rays are automatically created in a digital format.  The digitized snapshots are then put in order using a computer program and 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 to determine the presence or absence of abnormalitites. 

Videofluoroscopy and cineradiography are different names for the same procedure that utilizes a technique called fluoroscopy to create real-time video images of internal structures of the body.  Unlike standard x-rays that take a single picture at one point in time, videofluroscopy works more like a video camera, providing motion pictures of the inside 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 using the assistance of computer analysis software.

Definitions

Cineradiography (also known as Videofluoroscopy): A radiological procedure that uses fluoroscopy, an x-ray procedure, to make it possible to see structures in the body in real-time; this procedure has been proposed as a tool to diagnose or evaluate disease or injuries of the spine.

Digital motion x-ray: A technology in which successive x-rays are digitized and sequenced to create a video representation of movement of internal body structures.

Digitization: The process by which information is transformed from analog formats into digital computer-based formats.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the following procedure and diagnosis codes, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

CPT  
76120 Cineradiography/videoradiography, except where specifically included
76125 Cineradiography/videoradiography to complement routine examination
76496 Unlisted fluoroscopic procedure (eg, diagnostic, interventional) [when specified as videofluoroscopy]
   
ICD-10 Diagnosis  
M40.00-M40.57 Kyphosis and lordosis
M41.00-M41.9 Scoliosis
M42.00-M42.9 Spinal osteochondrosis
M43.00-M43.9 Other deforming dorsopathies
M45.0-M45.9 Ankylosing spondylitis
M46.00-M46.99 Other inflammatory spondylopathies
M47.011-M47.9 Spondylosis
M48.00-M48.9 Other spondylopathies
M49.80-M49.89 Spondylopathies in diseases classified elsewhere
M50.00-M50.93 Cervical disc disorders
M51.04-M51.9 Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders
M53.0-M53.9 Other and unspecified dorsopathies, not elsewhere classified
M54.00-M54.9 Dorsalgia
M80.08XA-M80.08XS Age-related osteoporosis with current pathological fracture, vertebra(e)
M80.88XA-M80.88XS Other osteoporosis with current pathological fracture, vertebra(e)
M81.0-M81.8 Osteoporosis without current pathological fracture
M88.1 Osteitis deformans of vertebrae
M88.89 Osteitis deformans of multiple sites
M99.00-M99.04 Segmental and somatic dysfunction of head, cervical, thoracic, lumbar, sacral regions
Q76.0-Q76.49 Congenital malformations of spine
S12.000A-S12.691S Fracture of cervical vertebra
S13.0XXA-S13.0XXS Traumatic rupture of cervical intervertebral disc
S13.100A-S13.181S Subluxation and dislocation of cervical vertebrae
S13.20XA-S13.29XS Dislocation of other and unspecified parts of neck
S13.4XXA-S43.4XXS Sprain of ligaments of cervical spine
S22.000A-S22.089S Fracture of thoracic vertebra
S23.0XXA-S23.0XXS Traumatic rupture of thoracic intervertebral disc
S23.100A-S23.171S Subluxation and dislocation of thoracic vertebra
S23.3XXA-S23.3XXS Sprain of ligaments of thoracic spine
S32.000A-S32.059S Fracture of lumbar vertebra
S32.10XA-S32.19XS Fracture of sacrum
S32.2XXA-S32.2XXS Fracture of coccyx
S33.0XXA-S33.0XXS Traumatic rupture of lumbar intervertebral disc
S33.100A-S33.141S Subluxation and dislocation of lumbar vertebra
S33.2XXA-S33.2XXS Dislocation of sacroiliac and sacrococcygeal joint
S33.30XA-S33.39XS Dislocation of other and unspecified parts of lumbar spine and pelvis
S33.5XXA-S33.9XXS Sprain of ligaments of lumbar spine, sacroiliac joint, other and unspecified parts of lumbar spine and pelvis
   
References

Peer Reviewed Publications:

  1. Harvey S, Hukins D, Smith F, et al. Measurement of lumbar spine intervertebral motion in the sagittal plane using videofluoroscopy. J Back Musculoskelet Rehabil. 2015; 29(3):445-457.
  2. Hino H, Abumi K, Kanayama M, Kaneda K. Dynamic motion analysis of normal and unstable cervical spines using cineradiography. An in vivo study. Spine (Phila Pa 1976). 1999; 24(2):163-168.
  3. Lindgren KA, Leino E, Manninen H. Cervical rotation lateral flexion test in brachialgia. Arch Phys Med Rehabil. 1992; 73(8):735-737.
  4. 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):1743-1749.
  5. Teyhen DS, Flynn TW, Childs JD, et al. Fluoroscopic video to identify aberrant lumbar motion. Spine. 2007; 32(7):E220-229.
  6. 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):1636-1641.
Websites for Additional Information
  1. National Institute of Neurological Disorders and Stroke. Low Back Pain Fact Sheet. Available at: http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm. Accessed on May 25, 2017.
  2. National Library of Medicine. Health Topics: Back Pain. Available at: http://www.nlm.nih.gov/medlineplus/backpain.html. Accessed on May 25, 2017.
Index

DXAnalyzer©

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History
Status Date Action
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.
Reviewed 08/04/2016 MPTAC review. Updated Coding and Reference sections. Removed ICD-9 codes from Coding section.
Reviewed 08/06/2015 MPTAC review.
Reviewed 08/14/2014 MPTAC review.
Reviewed 08/08/2013 MPTAC review.
Reviewed 08/09/2012 MPTAC review.
Reviewed 08/18/2011 MPTAC review.
Reviewed 08/19/2010 MPTAC review.
Reviewed 08/27/2009 MPTAC review.
Reviewed 08/28/2008 MPTAC review.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 08/18/2007 MPTAC review.
Reviewed 09/14/2006 MPTAC review.
Revised 09/22/2005 MPTAC Committee review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
     
Pre-Merger Organizations Last Review Date Document Number Title

Anthem, Inc.

 

10/28/2004 RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
WellPoint Health Networks, Inc.   None