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.

Purpose
Computed tomography (CT) is performed for the evaluation of the cervical spine. CT may be used as the primary imaging modality, or it may complement other modalities. Primary indications for CT include conditions, e.g., traumatic, neoplastic, and infectious. CT is often used to study the cervical spine for conditions such as degenerative disc disease when MRI is contraindicated. CT provides excellent depiction of bone detail and is used in the evaluation of known fractures of the cervical spine and for evaluation of postoperative patients.
 

Policy

INDICATIONS FOR CERVICAL SPINE CT
Evaluation of Neurologic Deficits^1,2
When Cervical Spine MRI Is Contraindicated or Inappropriate

• • Extremity muscular weakness (and not likely caused by plexopathy or peripheral neuropathy)
  • Pathologic (e.g., Babinski, Lhermitte's sign³, Chaddock Sign⁴, Hoffman’s and other upper motor neuron signs); OR abnormal deep tendon reflexes (and not likely caused by plexopathy, or peripheral neuropathy)
  • Absent/decreased sensory changes along a particular cervical dermatome (nerve distribution): pin prick, touch, vibration, proprioception, or temperature (and not likely caused by plexopathy or peripheral neuropathy)
  • Upper or lower extremity increase muscle tone/spasticity
  • 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)
• Suspected cord compression with any neurological deficits as listed above

Evaluation of Neck Pain^5,6
With Any of the Following When Cervical Spine MRI Is Contraindicated

• • 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 or weight loss or malaise,
  • Postural changes (e.g., kyphosis or scoliosis)
  • Limp (or refusal to walk in a younger child

Pre-Operative/Post-Operative/Procedural Evaluation
As part of initial pre-operative/post-operative/procedural evaluation (The best examinations are CT to assess for hardware complication, extent of fusion and pseudarthrosis and MRI for cord, nerve root compression, disc pathology, or post-op infection)(10)

Note: If ordered by Neurosurgeon or orthopedic surgeon for purposes of surgical planning, a contraindication to MRI is not required.

• For preoperative evaluation/planning
• CT discogram
• Evaluation of post operative pseudoarthrosis after initial X-rays (CT should not be done before 6 months after surgery)
• CSF leak highly suspected and supported by patient history and/or physical exam findings (leak [known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula -preferred exam CT myelogram])¹¹
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery in the last 6 months. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested (routine surveillance post-op not indicated without symptoms)
• Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
• New or changing neurological deficits or symptoms post-operatively¹² (see neurological deficit section above).
• When combo requests (see ⁺) are submitted (i.e., MRI and CT of the spine), the office notes should clearly document the need for both studies to be done simultaneously (e.g., the need for both soft tissue and bony anatomy is required)¹³
  • Combination requests where both cervical spine CT and MRI cervical spine are both approvable (not an all-inclusive list):
• • • OPLL (Ossification of posterior longitudinal ligament)¹⁴
    • Pathologic or complex fractures
    • Malignant process of spine with both bony and soft tissue involvement
    • Unstable craniocervical junction
    • Clearly documented indication for bony and soft tissue abnormality where assessment will change management for the patient

Evaluation of Suspected Myelopathy^15,16
When Cervical Spine MRI Is Contraindicated

• Does NOT require conservative care
• Progressive symptoms including hand clumsiness, worsening handwriting, difficulty with grasping and holding objects, diffuse numbness in the hands, pins and needles sensation, increasing difficulty with balance and ambulation
• Any of the neurological deficits as noted above

Evaluation of Trauma or Acute Injury¹⁷

• 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) (Both MRI and CT are approvable)^18,19
• When the patient is clinically unevaluable or there are preliminary imaging findings X-ray or CT) needing further evaluation
• When office notes specify the patient meets NEXUS (National Emergency X-Radiography Utilization Study) or CCR (Canadian Cervical Rules) criteria for imaging:¹⁷
  • CT for initial imaging
  • MRI when suspect spinal cord or nerve root injury or when patient is obtunded, and CT is negative
  • CT or MRI for treatment planning of unstable spine

MRI and CT provide complementary information. When indicated it is appropriate to perform both examinations
 

Evaluation of Known Fracture or New Compression Fractures^17,20
(With Worsening Neck Pain)

• To assess union of a fracture when physical examination, plain radiographs, or prior imaging suggest delayed or non-healing
• To determine the position of fracture fragments
• With history of malignancy (if MRI is contraindicated or cannot be performed)
• With an associated new focal neurologic deficit as above
• Prior to a planned surgery/intervention or if the results of the CT will change management

CT Myelogram^1,11
When MRI Cannot Be Performed/Contraindicated/Surgeon Preference

• When signs and symptoms inconsistent or not explained by the MRI findings
• Demonstration of the site of a CSF leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula)
• Surgical planning, especially regarding to the nerve roots or evaluation of dural sac
• Evaluation of suspected brachial plexus or nerve root injury in the neonate

Evaluation of Tumor, Cancer, or Metastasis
With Any of the Following:
MRI is usually the preferred study (CT may be needed to further characterize solitary indeterminate lesions seen on MRI)^6,21,22

• • With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
• • With an associated new focal neurologic deficit¹⁷
  • Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, radiculopathy or neck 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^6,24

Further Evaluation of Indeterminate Findings
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. When MRI cannot be performed, is contraindicated, or CT is preferred to characterize the finding⁶
• 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). When MRI cannot be performed, is contraindicated, or CT is preferred to characterize the finding.⁶

Evaluation of Known or Suspected Infection/Abscess²⁵
When Cervical Spine MRI Is Contraindicated

• 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 radiographic findings

E.g., Osteomyelitis

Evaluation of Known or Suspected Inflammatory Disease or Atlantoaxial Instability²⁶
When MRI Is Contraindicated or for Surgical Treatment Planning

• High-risk disorders affecting the atlantoaxial articulation, such as Down syndrome, Marfan syndrome with neurological signs/symptoms, abnormal neurological exam, or evidence of abnormal or inconclusive radiographs of the cervical spine²⁹
• Spondyloarthropathies, known or suspected
  • Ankylosing Spondylitis/Spondyloarthropathies with non-diagnostic or indeterminate x-ray and appropriate rheumatology workup

Evaluation of Spine Abnormalities Related to Immune System Suppression²⁵
When Cervical Spine MRI Is Contraindicated

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

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

Other Indications
When MRI Is Contraindicated or Cannot Be Performed

• Suspected neuroinflammatory Conditions/Diseases (e.g., sarcoidosis, Behcet’s)
  • After detailed neurological exam and appropriate initial work up

Initial evaluation of trigeminal neuralgia not explained on recent brain imaging

Combination Studies
Brain CT/Cervical Spine CT/Thoracic Spine CT/Lumbar Spine CT (any Combination)

• 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^{37,38,39,40,41}
• Oncological Applications (e.g., primary nervous system, metastatic)
  • Drop metastasis from brain or spine (CT spine imaging in this scenario is usually CT myelogram) see background
  • Suspected leptomeningeal carcinomatosis (see background)⁴⁰
  • Tumor evaluation and monitoring in neurocutaneous syndromes
• CSF leak highly suspected and supported by patient history and/or physical exam findings (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula - CT spine imaging in this scenario is usually CT myelogram)

Cervical Spine and Thoracic Spine CT
●    Initial evaluation of known or suspected syrinx or syringomyelia

• • With neurologic findings and/or predisposing conditions (e.g., Chiari malformation, prior trauma, neoplasm, arachnoiditis, severe spondylosis)³⁵
  • To further characterize a suspicious abnormality seen on prior imaging
  • Known syrinx with new/worsening symptom

Cervical Spine and/or Thoracic Spine and/or Lumbar Spine CTs (Any Combination)
Note: These body regions might be evaluated separately or in combination as documented in the clinical notes by physical examination findings (e.g., localization to a particular segment of the spinal cord), patient history, and other available information, including prior imaging.

Exception: Indications for combination studies^42,43 are approved indications as noted below and being performed in children who will need anesthesia for the procedure

• • Suspected leptomeningeal carcinomatosis (LC)⁵¹
  • Any combination of these for spinal survey in patient with metastases
  • Tumor evaluation and monitoring in neurocutaneous syndromes
• CSF leak highly suspected and supported by patient history and/or physical exam findings (leak [known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula -preferred exam CT myelogram])¹¹
• CT myelogram when meets above guidelines and MRI is contraindicated or for surgical planning
• Post-procedure (discogram) CT

Combination Studies for Malignancy for Initial Staging or Restaging

• 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

Other

• When MRI is contraindicated OR cannot be performed OR Surgeon preference

BACKGROUND
Computed tomography (CT) is performed for the evaluation of the cervical spine. CT may be used as the primary imaging modality, or it may complement other modalities. Primary indications for CT include conditions, e.g., traumatic, neoplastic, and infectious. CT is often used to study the cervical spine for conditions such as degenerative disc disease when MRI is contraindicated. CT provides excellent depiction of bone detail and is used in the evaluation of known fractures of the cervical spine and for evaluation of postoperative patients.

Special Note
+If there is a combination request* for an overlapping body part, either requested at the same time or sequentially (within the past 3 months):

• The results of the prior study should be inconclusive or show a need for inconclusive or show a need for additional or follow-up imaging evaluation OR
• The office notes should clearly document an indication why overlapping imaging is needed and how it will change management for the patient.

(*Unless approvable in the combination section as noted in the guidelines)
 

OVERVIEW
*Conservative Treatment
Non-operative conservative treatment should include a multimodality approach consisting of at least one active and one 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)

**Home Exercise Program
The following two elements are required to meet conservative therapy guidelines for HEP:¹⁰

• 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).

Cervical Myelopathy
Symptom severity varies, and a high index of suspicion is essential for making the proper diagnosis in early cases. Symptoms of pain and radiculopathy may not be present. The natural history of myelopathy is characterized by neurological deterioration. The most frequently encountered symptom is gait abnormality (86%) followed by increased muscular reflexes (79.1%), pathological reflexes (65.1%), paresthesia of upper limb (69.8%) and pain (67.4%).(15)

Gait and Spine Imaging
Table 1^{52,53,54,55,56,57}

CT Myelogram
Myelography is the instillation of intrathecal contrast media under fluoroscopy. Patients are then imaged with CT to evaluate for spinal canal pathology. Although this technique has diminished greatly due to the advent of MRI due to its non-invasiveness and superior soft- tissue contrast, myelography is still a useful technique for conventional indications, such as spinal stenosis, when MRI is contraindicated or nondiagnostic or surgeon preference (see guidelines above), brachial plexus injury in neonates, radiation therapy treatment planning, and cerebrospinal fluid (CSF) leak.⁵⁸

Contraindication and Preferred Studies

• 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 weight limit/dimensions of MRI machine

References

Coding Section

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.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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