Description
Magnetic resonance imaging (MRI) is used in the evaluation, diagnosis, and management of spine-related conditions, e.g., degenerative disc disease, cauda equine compression, radiculopathy, infections, or cancer in the lumbar spine. MRI provides high quality multiplanar images of organs and structures within the body without the use of X-rays or radiation. In the lumbar area where gonadal exposure may occur, MRI’s lack of radiation is an advantage.

GENERAL INFORMATION

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 
• Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Policy
Lumbar spine MRI is considered MEDICALLY NECESSARY for the following indications:

• With any of the following new neurological deficits documented on physical exam that localizes to the lumbar spine
  • Extremity muscular weakness (not likely caused by plexopathy, peripheral neuropathy or neuromuscular disease)
  • Pathologic abnormal reflexes (not likely caused by plexopathy, peripheral neuropathy or neuromuscular disease)
  • Absent/decreased sensation along a particular lumbar dermatome (nerve distribution): pin prick, touch, vibration, proprioception or temperature (and not likely caused by plexopathy, or peripheral neuropathy)
  • Lower extremity decreased muscle tone (not likely caused by plexopathy, peripheral neuropathy or neuromuscular disease)
  • New onset bowel or bladder dysfunction (e.g., retention or incontinence)—not related to an inherent bowel or bladder process
  • Gait abnormalities (see Table 1 below for more details)
  • New onset foot drop (not related to a peripheral nerve injury, e.g., peroneal nerve)
• Cauda Equina Syndrome as evidence by severe back pain/sciatica along with one of the defined symptoms (see Cauda Equina Syndrome section)

With any of the Following:

• With new or worsening objective neurologic deficits on exam, as above
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months:

NOTE - Failure of conservative treatment is defined as one of the following:

• • Lack of meaningful improvement after a full course of treatment; OR
  • Progression or worsening of symptoms during treatment; OR
  • Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• With progression or worsening of symptoms during the course of conservative treatment*

• With an abnormal electromyography (EMG) or nerve conduction study (if performed) indicating a lumbar radiculopathy. ^(2,3)
• Isolated back pain in pediatric population when at least ONE of the following red flags are present ^(4,5) (Note: conservative care not required if red flags are present).
  • Age 5 or younger
  • Constant pain
  • Pain lasting > 4 weeks
  • Abnormal neurologic examination
  • Early morning stiffness and/or gelling
  • Night pain that prevents or disrupts sleep
  • Radicular pain
  • Fever, weight loss, or malaise
  • Postural changes (e.g., kyphosis or scoliosis)
  • Limp (or refusal to walk in a younger child)

• Presents with any of the following neurological deficits as above
• With progression or worsening of symptoms during the course of conservative treatment
• History of underlying spinal abnormalities (i.e., ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis) (Both MRI and CT are approvable) ^(7,8)
• When the patient is clinically unevaluable or there are preliminary imaging findings (x-ray or CT) needing further evaluation

• Pars defect (spondylolysis) or spondylolisthesis in adults when Flexion/Extension x-rays show instability ⁽⁹⁾
• Clinically suspected pars defect (spondylolysis) after plain films (flexion extension instability not required) in pediatric population (< 18 yr.) or athletes and imaging would change treatment ⁽⁴⁾

• With history of malignancy
  • To aid in differentiation of benign osteoporotic fractures from metastatic disease
    • A follow-up MRI in 6-8 weeks after initial MRI when initial imaging cannot decipher (indeterminate) benign osteoporotic fracture from metastatic disease
• Fracture on initial imaging in a young patient (< 50) with no history of trauma and concern for pathologic fracture
• Fracture with imaging characteristics concerning for underlying malignancy
• With an associated new focal neurologic deficit as above
• Prior to a planned surgery/intervention or if the results of the MRI will change management

With any of the Following:

• Primary tumor ⁽¹¹⁾
  • Initial staging primary spinal tumor
  • Follow-up of known primary cancer of patient undergoing active treatment within the past year or as per surveillance imaging guidance for that cancer
  • Known spinal tumor with new signs or symptoms (e.g., new or increasing nontraumatic pain, physical, laboratory, and/or imaging findings)
  • With an associated new focal neurologic deficit as above
• Metastatic tumor ⁽¹²⁾  
  • With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
  • With an associated new focal neurologic deficit
  • Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, radiculopathy or back pain that occurs at night and wakes the patient from sleep with known active cancer, physical, laboratory, and/or imaging findings) in a tumor that tends to metastasize to the spine ⁽¹³⁾

E.g. Osteomyelitis or abscess

• As evidenced by signs and/or symptoms, laboratory (i.e., abnormal white blood cell count, ESR and/or CRP) or prior imaging findings
• Follow-up imaging of infection
  • With worsening symptoms/laboratory values (i.e., white blood cell count, ESR/CRP) or x-ray findings

• Spondyloarthropathies, known or suspected
  • Ankylosing Spondylitis/Spondyloarthropathies with non-diagnostic or indeterminate x-ray and appropriate rheumatology workup
• Known and suspected neuroinflammatory conditions (such as sarcoidosis, Bechet’s)
  • Initial evaluation of suspected neuroinflammatory conditions after initial workup and detailed neurological examination
  • Follow-up of known neuroinflammatory conditions when there are either:
    • New or worsening signs or symptoms OR
    • To evaluate treatment response

E.g., HIV, chemotherapy, leukemia, or lymphoma

• As evidenced by signs/symptoms, laboratory, or prior imaging findings

Note: See combination requests, below, for initial advanced imaging assessment and pre-operatively

• Tethered cord or spinal dysraphism (known or suspected), based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata ^(15,16)
• Known anorectal malformations ⁽¹⁷⁾
• Suspicious sacral dimple (those that are deep, larger than 0.5 cm, located within the superior portion of the gluteal crease or above the gluteal crease, multiple dimples, or associated with other cutaneous markers) or duplicated or deviated gluteal cleft ⁽¹⁸⁾
  • Patients <3 months should have ultrasound
• Toe walking in a child when associated with upper motor neuron signs, including hyperreflexia, spasticity; or orthopedic deformity with concern for tethered cord (e.g., pes cavus, clawed toes, leg or foot length deformity (excluding tight heel cords)) ⁽¹⁹⁾
• Known Chiari II (Arnold-Chiari syndrome), III, or IV malformation ⁽¹⁵⁾
• For follow-up/repeat evaluation of Arnold-Chiari I with new signs or symptoms suggesting recurrent spinal cord tethering (For initial diagnosis see Combinations section below)
• CSF leak highly suspected and supported by patient history and/or physical exam findings (e.g., known or suspected spontaneous intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula) ⁽²⁰⁾

When not otherwise specified in the guideline:

Preoperative Evaluation:

• Imaging of the area requested is needed to develop a surgical plan

Postoperative Evaluation:

• Evaluation of postoperative pseudarthrosis, hardware complication and/or extent of fusion after initial x-rays

NOTE: for this indication, advanced imaging should not occur until > 6 months after surgery

• Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
• New or changing neurological deficits or symptoms post-operatively ⁽²¹⁾ (see neurological deficit section above)
• Known or suspected complications
• A clinical reason is provided how imaging may change management

NOTE: This section applies only within the first few months following surgery unless otherwise specified

Unless follow-up is otherwise specified within the guideline

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification.
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam).

• LZTR1-related Schwannomatosis ⁽²²⁾ :
  • Every 2 years starting at age 12
• Neurofibromatosis 1 (NF1) ^(23,24) :
  • Signs and symptoms concerning for spinal tumor
• NF2-Related Schwannomatosis ⁽²⁵⁾ :
  • Prior to regional anesthesia OR
  • Signs and symptoms concerning for spinal tumor
• SMARCA4 and SMARCB1 (includes SMARCB1-associated Schwannomatosis and Rhabdoid Tumor Predisposition Syndrome) ^(22,26) :
  • At diagnosis
  • Monthly from age 0-6 months
  • Every 2 months from age 7-18 months
  • Every 3 months from age 19 months – 5 years
  • Annually after age 5
• Von Hippel-Lindau (VHL) ⁽²⁷⁾ :
  • Annually (including at diagnosis) starting at age 11
• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance.

Combination Studies for Known Genetic Conditions

NOTE: When medical necessity is met for an individual study AND conscious sedation is required (such as for young pediatric patients or patients with significant developmental delay), the entire combination is indicated

• Marfan Syndrome ⁽²⁸⁾ :
  • For low back pain, proximal leg pain, genital/rectal pain OR weakness and numbness above knee
• NF2-Related Schwannomatosis ⁽²⁵⁾ :
  • Signs and symptoms concerning for spinal tumor

Brain/Cervical Spine/Thoracic Spine/Lumbar Spine MRI

• LZTR1-related Schwannomatosis ⁽²²⁾ :
  • Every 2 years starting at age 12
• Neurofibromatosis 1 (NF1) ^(23,24) :
  • Signs and symptoms concerning for spinal tumor

• Von Hippel-Lindau (VHL) ⁽²⁷⁾ :
  • Annually (including at diagnosis) starting at age 11

• SMARCA4 and SMARCB1 (includes SMARCB1-associated Schwannomatosis and Rhabdoid Tumor Predisposition Syndrome) ^(22,26) :
  • At diagnosis
  • Monthly from age 0-6 months
  • Every 2 months from age 7-18 months
  • Every 3 months from age 19 months – 5 years
  • Annually after age 5

NOTE: When medical necessity is met for an individual study AND conscious sedation is required (such as for young pediatric patients or patients with significant developmental delay), the entire combination is indicated

• Pathologic or complex fractures
• Malignant process of spine with both bony and soft tissue involvement
• Clearly documented indication for bony and soft tissue abnormality where assessment will change management for the patient

• For initial evaluation of a suspected Arnold Chiari malformation

• Follow-up imaging of a known type II or type III Arnold Chiari malformation. For Arnold Chiari type I, follow-up imaging only if new or changing signs/symptoms ^(15,29–31)
• Oncological Applications (e.g., primary nervous system, metastatic) ⁽¹¹⁾
  • Drop metastasis from brain or spine
  • Suspected leptomeningeal carcinomatosis ⁽³²⁾
  • Known tumor evaluation and monitoring in neurocutaneous syndromes
• CSF leak highly suspected and supported by patient history and/or physical exam findings (e.g. known or suspected spontaneous intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula) ⁽²⁰⁾

• Survey/complete initial assessment of infant/child with congenital scoliosis or juvenile idiopathic scoliosis under the age of 10 ^(33,34) (e.g., congenital scoliosis, idiopathic scoliosis, scoliosis with vertebral anomalies)
• In the presence of neurological deficit, progressive spinal deformity, or for preoperative planning ^(35,36)
• Back pain with known vertebral anomalies (hemivertebrae, hypoplasia, agenesis, butterfly, segmentation defect, bars, or congenital wedging) in a child on preliminary imaging
• Scoliosis with any of the following ^(36,37) :
  • Progressive spinal deformity
  • Neurologic deficit (new or unexplained)
  • Early onset
  • Atypical curve (e.g., short segment, >30^◦ kyphosis, left thoracic curve, associated organ anomalies)
  • Pre-operative planning
  • When office notes clearly document how imaging will change management
• Arnold-Chiari malformations ^(15,38)
  • Arnold-Chiari I
    • For evaluation of spinal abnormalities associated with initial diagnosis of Arnold-Chiari Malformation. (C/T/L spine due to association with tethered cord and syringomyelia), and initial imaging has not been completed ⁽³⁴⁾
  • Arnold-Chiari II-IV - For initial evaluation and follow-up as appropriate
    • Usually associated with open and closed spinal dysraphism, particularly meningomyelocele ⁽³⁹⁾
• Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata, ^(15,16,39) when anesthesia required for imaging ⁽⁴⁰⁾ (e.g., meningomyelocele, lipomeningomyelocele, diastematomyelia, fatty/thickened filum terminale, and other spinal cord malformations)
• Oncological Applications (e.g., primary nervous system, metastatic) ⁽¹¹⁾
  • Drop metastasis from brain or spine (imaging also includes brain)
  • Suspected leptomeningeal carcinomatosis (LC) ⁽⁴¹⁾
  • Known tumor evaluation and monitoring in neurocutaneous syndromes
• CSF leak highly suspected and supported by patient history and/or physical exam findings (e.g. known or suspected spontaneous intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula) ⁽²⁰⁾

Unless otherwise specified in this guideline, indication for combination studies for malignancy for initial staging or restaging:

• Concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Abdomen, Brain, Chest, Neck, Pelvis, Cervical Spine, Thoracic Spine or Lumbar Spine.

BACKGROUND/Rationale
*Conservative Treatment
Non-operative conservative treatment should include a multimodality approach consisting of at least one (1) active and one (1) inactive component targeting the affected region. 

Active Modalities

• Physical therapy
• Physician-supervised home exercise program**
• Chiropractic care

Inactive Modalities

• Medications (e.g., NSAIDs, steroids, analgesics)
• Injections (e.g., epidural injection, selective nerve root block)
• Medical Devices (e.g., TENS unit, bracing)

The following two elements are required to meet conservative therapy guidelines for HEP  ⁽¹⁾ :

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor; AND
• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (e.g., increased pain or inability to physically perform exercises).

• Symptoms include severe back pain or sciatica along with one or more of the following:
  • Saddle anesthesia - loss of sensation restricted to the area of the buttocks, perineum, and inner surfaces of the thighs (areas that would sit on a saddle)
  • Recent bladder/bowel dysfunction
  • Achilles reflex absent on both sides
  • Sexual dysfunction that can come on suddenly
  • Absent anal reflex and bulbocavernosus reflex

• Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester)

• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non-compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine

Summary of Evidence

ACR Appropriateness Criteria® Low Back Pain: 2021 Update ⁽¹⁾

Study Design: The study is an update of the ACR Appropriateness Criteria for low back pain, developed by the Expert Panel on Neurological Imaging. The criteria are evidence-based guidelines for specific clinical conditions, reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios.

Target Population: The target population includes patients in the United States with acute low back pain, with or without radiculopathy. Acute low back pain is the leading cause of years lived with disability and the third-ranking cause of disability-adjusted life-years in the United States. The criteria address various scenarios, including uncomplicated acute low back pain, subacute or chronic low back pain, low back pain with suspected cauda equina syndrome, low back pain with a history of prior lumbar surgery, and low back pain with one or more risk factors such as low-velocity trauma, osteoporosis, elderly individuals, or chronic steroid use.

Key Factors

Imaging Recommendations: The criteria provide detailed recommendations on the appropriateness of various imaging procedures for different clinical scenarios. For example, imaging is typically not warranted for acute uncomplicated low back pain, while MRI is recommended for patients with suspected cauda equina syndrome or those who are candidates for surgery or intervention with persistent or progressive symptoms.

Clinical Scenarios: The document outlines seven variants of low back pain and provides specific imaging recommendations for each variant. These include acute low back pain with or without radiculopathy, subacute or chronic low back pain, low back pain with suspected cauda equina syndrome, low back pain with a history of prior lumbar surgery, and low back pain with risk factors such as low-velocity trauma, osteoporosis, elderly individuals, or chronic steroid use.

Radiation Levels: The criteria also include relative radiation level designations for each imaging examination, providing information on potential adverse health effects associated with radiation exposure.

ACR Appropriateness Criteria® Acute Spinal Trauma ⁽⁶⁾

Study Design: The document is a revised guideline by the American College of Radiology (ACR) for the appropriateness of imaging procedures in acute spinal trauma. It includes a summary of literature reviews, expert panel recommendations, and evidence-based criteria for various clinical scenarios.

Target Population: The guidelines focus on patients aged 16 years and older who have experienced acute blunt trauma to the cervical, thoracic, or lumbar spine. Specific criteria are provided for different age groups and clinical conditions, including low-risk patients, those with suspected arterial injury, and obtunded patients.

Key Factors:

Imaging Procedures: The document outlines the appropriateness of various imaging modalities such as CT, MRI, MRA, and radiography for different clinical scenarios. It emphasizes the use of CT without IV contrast as the initial imaging modality for most cases.

Clinical Criteria: The guidelines incorporate the NEXUS and Canadian C-Spine Rule (CCR) criteria for determining the need for cervical spine imaging. These criteria are based on factors such as age, mechanism of injury, and clinical symptoms.

Radiation Levels: The document includes relative radiation level designations for each imaging procedure, highlighting the importance of minimizing radiation exposure.

Expert Panel: The guidelines were developed by an expert panel on neurological imaging, including specialists from various institutions and organizations.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update ⁽¹⁰⁾

Study Design: The study design involves the development and revision of the ACR Appropriateness Criteria, which are evidence-based guidelines for specific clinical conditions. These guidelines are reviewed annually by a multidisciplinary expert panel. The guideline development includes an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies such as the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios.

Target Population: The target population for this study includes individuals with vertebral compression fractures, which can be caused by various etiologies such as trauma, osteoporosis, or neoplastic infiltration. Osteoporosis-related fractures are the most common cause of VCFs and have a high prevalence among postmenopausal women and similarly aged men. The study also addresses VCFs caused by trauma and malignancies, including primary bone tumors and metastatic cancers.

Key factors:

• The prevalence and causes of VCFs, highlighting the high incidence among postmenopausal women and the increasing incidence in men.
• The importance of diagnostic imaging in characterizing VCFs and guiding treatment decisions.
• The use of various imaging modalities such as MRI, CT, FDG-PET/CT, and bone scans to evaluate VCFs.
• The management of both osteoporotic and pathologic VCFs, including medical management, percutaneous vertebral augmentation, and surgical consultation.
• The role of minimally invasive percutaneous image-guided techniques for treating spine tumors and the potential benefits of vertebral augmentation procedures.

Analysis of Evidence

Shared Findings

Imaging Recommendations: All three articles emphasize the importance of imaging in diagnosing and managing spinal conditions. They recommend using MRI and CT scans as primary imaging modalities due to their high sensitivity and specificity in detecting spinal injuries and abnormalities. For instance, "Hassankhani et al 2024 ACR Acute Spinal Trauma" highlights the use of CT and MRI for acute spinal trauma, while "Hutchins et al 2021 JACR Low Back Pain" and "Khan et al 2023 JACR Management of Vertebral Compression Fractures" also stress the importance of these imaging techniques for low back pain and vertebral compression fractures, respectively. ^(1,6,10)

Clinical Criteria and Guidelines: The articles provide evidence-based guidelines and criteria for managing spinal conditions. "Hassankhani et al 2024 ACR Acute Spinal Trauma" discusses the use of the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-Spine Rule (CCR) for cervical spine injuries. ⁽⁶⁾ Similarly, "Hutchins et al 2021 JACR Low Back Pain" outlines the American College of Radiology Appropriateness Criteria for low back pain management. ⁽¹⁾ "Khan et al 2023 JACR Management of Vertebral Compression Fractures" provides guidelines for managing vertebral compression fractures, including the use of the Spinal Instability Neoplastic Score (SINS) for evaluating spinal stability. ⁽¹⁰⁾

Non-Surgical Management: All three articles emphasize the importance of non-surgical management as the first line of treatment. They recommend conservative therapies such as pain management, physical therapy, and bracing before considering surgical interventions. For example, "Hutchins et al 2021 JACR Low Back Pain" and "Khan et al 2023 JACR Management of Vertebral Compression Fractures" both highlight the role of conservative management in treating low back pain and vertebral compression fractures. ^(1,10)

References 

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. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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