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CT Lumbar Spine - CAM 713HB

Description 

Description
Computed tomography is used for the evaluation, assessment of severity, and follow-up of diseases of the spine. Its use in the thoracic spine is limited, however, due to the lack of epidural fat in this part of the body. CT myelography improves the contrast severity of CT, but it is also invasive. CT may be used for conditions, e.g., degenerative changes, infection, and immune suppression, when magnetic resonance imaging (MRI) is contraindicated. It may also be used in the evaluation of tumors, cancer, or metastasis in the thoracic spine, and it may be used for preoperative and post-surgical evaluations. CT obtains images from different angles and uses computer processing to show a cross-section of body tissues and organs. CT is fast and is often performed in acute settings. It provides good visualization of cortical bone.

OVERVIEW
*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)

**Home Exercise Program
The following elements are required to meet for conservative therapy guidelines for HEP: (2)

  • 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).

Gait and Spine Imaging

Table 1 (41)

Gait

Characteristic

Work up/Imaging

Hemiparetic

Spasticunilateral, circumduction

Brain and/or, Cervical spine imaging based on associated symptoms

Diplegic

Spastic bilateral, circumduction

Brain,CervicalandThoracicSpine imaging

Myelopathic

Wide based, stiff, unsteady

Cervical and/or Thoracic spine MRI based on associated symptoms
 

Cerebellar Ataxic

Broad based, clumsy, staggering, lack of coordination, usually also with limb ataxia

Brain imaging see Brain MRI Guideline

Apraxic

Magnetic,shuffling,difficulty initiating

Brain imaging see Brain MRI Guideline

Parkinsonian

Stooped, small steps, rigid, turning en bloc, decreased arm swing

Brain Imaging see Brain MRI Guideline

Choreiform

Irregular,jerky,involuntary movements

Medication review, consider brain imaging as per movement disorder Brain MR guidelines

Sensory ataxic

Cautious,stomping,worsening without visual input (ie + Romberg)

EMG, blood work, consider spinal (cervical or thoracic cord imaging) imaging based on EMG

Neurogenic

Steppage, dragging of toes
  • EMG initial testing;
  • BUT if there is a foot drop, lumbar spine MRI is appropriate without EMG
  • Pelvis MR if there is evidence of plexopathy

Vestibular

Insecure, veer to one side, worse when eyes closed, vertigo

Consider Brain/IAC MRI see Brain MRI Guideline

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, nondiagnostic, or surgeon preference (see guidelines above), brachial plexus injury in neonates, radiation therapy treatment planning, and cerebrospinal fluid (CSF) leak.
 

Cauda Equina Syndrome

  • 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
  • This is a “Red Flag” situation and Lumbar Spine MRI is approvable.

Contraindications 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 wight limit/dimensions of MRI machine

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.
 

Policy
INDICATIONS FOR LUMBAR SPINE CT
Evaluation of Neurologic Deficits
When Lumbar Spine MRI is Contraindicated or Inappropriate

With any of the following new neurological deficits documented on physical exam

  • Extremity muscular weakness (and not likely caused by plexopathy or peripheral neuropathy)(1)
  • Pathologic or abnormal reflexes (and not likely caused by plexopathy, or peripheral neuropathy)
  • Absent/decreased sensory changes along a particular lumbar dermatome (nerve distribution): pin prick, touch, vibration, proprioception, or temperature weakness (and not likely caused by plexopathy, or peripheral neuropathy)
  • Lower extremity increased muscle tone
  • New onset bowel or bladder dysfunction (e.g., retention or incontinence)—not related to an inherent bowel or bladder process
  • Gait abnormalities (see Table 1below 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 Syndromesection)


Evaluation of Back Pain (2)
With any of the following when Lumbar Spine MRI is Contraindicated

  • With new or worsening objective neurologicdeficitson exam, as above
  • Failure of conservative treatment*for at 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. (EMG is not recommended to determine the cause of axial lumbar, thoracic, or cervical spine pain)(3)
  • Isolated back pain in pediatric population(4,5) (conservative care not required if red flags present). Red flags that prompt imaging include any ONE of the following:
  • 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)(5)

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)(2)

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))(6)
  • 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-operatively(7) (2)(see

neurological deficitsection above).

  • When combo requestsare 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)(8)
  • Combination requests where both lumbar spine CT and MRI lumbar spine are both approvable (not an all-inclusive list):
    • 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

Evaluation of Trauma or Acute Injury (9)

  • Presents with any of the following neurologicaldeficitsas 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)(10)
  • When the patient is clinically unevaluable or there are preliminary imaging findings (x-ray or CT) needing further evaluation
  • MRI and CT provide complementary information. When indicated it is appropriate to perform both examinations

Evaluation of Known Fracture or New Compression Fractures (9,11)
(With Worsening Back 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 neurologicdeficitas above
  • Prior to a planned surgery/intervention or if the results of the CT will change management

CT Myelogram (6,12)
When MRI cannot be Performed/Contraindicated/Surgeon Preference

  • When signs and symptoms are 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

Pars defect or spondylolisthesis

  • Pars defect (spondylolysis) or spondylolisthesis in adults when Flexion/Extension x- rays show instability(13)
  • Clinically suspected Pars defect (spondylolysis) after plain films in pediatric population (< 18 yr.), or athletes (flexion extension instability not required) and imaging would change treatment (4) when MRI is contraindicated/cannot be performed or surgeon preference

NOTE: Initial imaging (x-ray, or planar bone scan without SPECT; Bone scan with SPECT is
superior to MRI and CT in the detection of pars interarticularis pathology including
spondylolysis)(4)

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)(14,15)

  • Primary tumor
  • Initial staging primary spinal tumor(16)
  • 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 neurologicdeficitas above(9)
  • Metastatic tumor
  • 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(9)
  • 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(15,17)

Further Evaluation of Indeterminate Findings (15)
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 finding.
  • One follow-up exam of a prior indeterminate MRI/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).

Evaluation of Known or Suspected
Infection/Abscess/Inflammatory disease (18,19)

When Lumbar Spine MRI is contraindicated

  • Infection
  • 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
  • Spondyloarthropathies
  • Ankylosing Spondylitis/Spondyloarthropathies with non-diagnostic or indeterminate x-ray and rheumatology workup

E.g., Osteomyelitis

Evaluation of Spine Abnormalities Related to Immune
System Suppression (19)
When Lumbar Spine MRI is Contraindicated

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

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

Other Indications for a Lumbar Spine CT
When MRI is Contraindicated or Cannot be Performed
Note: See combination requests, below, for initial advanced imaging assessment and preoperatively

  • Tethered cord or spinal dysraphism (known or suspected), based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata(20,21,22)
  • Known anorectal malformations(23)
  • 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(24)
    • in 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 spinal cord pathology/tethered cord (e.g., pes cavus, clawed toes, leg, or foot length deformity (excluding tight heel cords))(25)
  • Known Chiari II (Arnold-Chiari syndrome), III, or IV malformation(22)
  • For follow-up/repeat evaluation of Arnold-Chiari I with new signs or symptoms suggesting recurrent spinal cord tethering (For initial diagnosis see below)
  • Suspected neuroinflammatory Conditions/Diseases (e.g., sarcoidosis, Behcet’s)- After detailed neurological exam and appropriate initial work up completed
  • Follow-up known neuroinflammatory Conditions/Diseases (e.g., sarcoidosis,

Behcet’s) with new or worsening signs/symptoms or to evaluate treatment response


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

(26,27,28,29,30)

  • 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) (30)
    • 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 and/or Thoracic and/or Lumbar 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(31,32): Are approved indications as noted
below and being performed in children who will need anesthesia for the procedure

  • Any combination of these studies for:
    • Survey/complete initial assessment of infant/child with congenital scoliosis or juvenile idiopathic scoliosis under the age of 10(33,34,35) (e.g., congenital scoliosis, idiopathic scoliosis, scoliosis with vertebral anomalies)
    • In the presence of neurological deficit, progressive spinal deformity, or for preoperative planning(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(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; OR
      • When office notes clearly document how imaging will change management
  • Arnold-Chiari malformations(22,38)
    • 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(33)
    • Arnold-Chiari II-IV - For initial evaluation and follow-up as appropriate
      • Usually associated with open and closed spinal dysraphism, particularly meningomyelocele(20)
  • Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata,(20,21,22) when anesthesia required for imaging(39) (e.g., meningomyelocele, lipomeningomyelocele, diastematomyelia, fatty/thickened filum terminale, and other spinal cord malformations)
  • Oncological Applications (e.g., primary nervous system, metastatic)
  • Drop metastasis from brain or spine (imaging also includes brain; CT spine imaging in this scenario is usually CT myelogram)
  • Suspected leptomeningeal carcinomatosis (LC)(40)
  • 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))(6)
  • 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.

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Coding Section

Codes

Number

Description

CPT

72131

Computed tomography, lumbar spine; without contrast material 

 

72132

with contrast material 

 

72133

without contrast material, followed by contrast material(s) and further sections

 

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, Blue Cross Blue Shield Association technology assessment program (TEC) 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" 

History From 2024 Forward 

12/02/2024
Annual review, no change to policy intent. Policy reformatted for clarity and consistency. Adding Contraindication/preferred studies, updating references.
01/01/2024 New Policy
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