Medical Policy

 

 

Subject: Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
Document #: RAD.00034 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

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 dynamic spinal visualization, including digital motion x-rays, cineradiography, and 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, cineradiography, and 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 digitally or on film, to allow visualization of internal structures while an individual is moving.  These technologies have been proposed for the evaluation of back pain, orthopedic issues, and other conditions.

Digital motion x-ray involves the use of either film x-ray or computer-based x-ray ‘snapshots’ taken in sequence as an individual 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 format into digital computer-based format.

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-S13.4XXS

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 07, 2018.
  2. National Library of Medicine. Health Topics: Back Pain. Available at: http://www.nlm.nih.gov/medlineplus/backpain.html. Accessed on May 07, 2018. 
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

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References section.

Reviewed

08/03/2017

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