Anthem Blue Cross Connecticut RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy) Form

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.