MRI (Magnetic Resonance Imaging) of the Spine (Cervical, Thoracic, Lumbar) Form

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MRI (Magnetic Resonance Imaging) of the Spine (Cervical, Thoracic, Lumbar) Medical Guideline

Service: MRI of the Spine (Cervical, Thoracic, Lumbar)

PUM 250-0057-1812

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026

Description: Magnetic Resonance Imaging (MRI) of the spine provides high contrast imaging of the spine and allows for high resolution evaluation of the spinal cord and surrounding structures. It is commonly used to evaluate disc pathology, abnormalities of the spinal cord and thecal sac, and the bones of the spinal column.

Indications of Coverage:

MRI of the Spine (Lumbar, Thoracic, or Cervical) is considered medically necessary when at least ONE of the following criteria are met:

A. Back or neck pain when at least ONE of the following is met:

i. a “red flag” indication listed below
ii. new or worsening neurologic deficits* noted on physical exam. iii. Electromyography or nerve conduction studies (EMG/NCV) are indicative of radiculopathy. iv. Symptoms which have not responded to at least a six-week trial of conservative treatment within the last 6 months or during the current episode of pain (as described below). ***
v. Progression or worsening of symptoms during a trial of conservative treatment.

*In the presence of “red flag” findings, MRI of the spine should be approved as medically necessary, and no trial of active conservative treatment is required. “Red Flag findings” include:

a) new or unexplained motor weakness.
b) new sensory deficits (pinprick, touch, vibration, temperature) in a dermatomal distribution and unlikely to be due to peripheral neuropathy).
c) cauda equina syndrome d) suspected infection

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e) severe radicular pain requiring ED visit
f) new or unexplained bowel or bladder dysfunction (unrelated to bowel or bladder disorder) g) back or neck pain at age 5 or younger h) unexplained pediatric limping or refusal to walk.

** Neurologic deficits on physical exam include:
a) unexplained muscle weakness (to include foot drop) not likely to be due to peripheral neuropathy.

b) new sensory deficits (pinprick, touch, vibration, temperature) in a

dermatomal distribution and unlikely to be due to peripheral neuropathy).
c) abnormal upper motor neuron signs, such as unexplained Lhermitte’s or
Babinski’s or Hoffmann’s signs, or unexplained hyperreflexia or unexplained bilateral motor weakness.
d) new, abnormal deep tendon reflexes, unlikely to be due to peripheral neuropathy.
e) new onset of bowel or bladder incontinence or retention (unlikely related to inherent process in the bowel or bladder).
***A trial of conservative treatment is defined as a combination of both active and inactive components, directed at the area of interest during the current episode of pain. Inactive components include medications (such as analgesics, anti-inflammatory medications, muscle relaxants), rest, ice, heat, or injections/acupuncture. Active modalities include either Physical Therapy, Chiropractic or osteopathic manipulations, or a physician assisted home exercise program.

B. For evaluation of spondylolysis/spondylolisthesis, MRI of the lumbar spine is considered medically necessary if either:

a) adult patient and alternate imaging (plain films, Bone scan, CT) is indeterminate or additional information needed. (Unless one of the indications in A. i.-v. (above) is met, a trial of conservative treatment is required), OR
b) pediatric population when alternate imaging is inconclusive and additional imaging would alter management.

FOR EACH OF THE FOLLOWING, C-T, A TRIAL OF CONSERVATIVE THERAPY IS NOT REQUIRED:

C. Back or Neck Pain with abnormal EMG, suggestive of radiculopathy. No trial of conservative treatment is required; however, a repeat MRI will be

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considered not medically necessary in the absence of new or changing clinical findings.

D. Trauma/Compression Fractures –With fracture documented on plain films and/or CT and ONE of the following:

i. Pathologic fractures
ii. Complex fractures
iii. Findings from x-rays or CT require further evaluation.

NOTE: In the setting of acute trauma, preceding plain films or CT are not required with EITHER a) associated neurologic deficits; OR b) obtunded patient and spinal or nerve root injury suspected.

E. Inflammatory spondylitis, such as ankylosing spondylitis/spondyloarthropathy or diffuse idiopathic skeletal hyperostosis and:

i. plain films are not diagnostic, or are equivocal OR
ii. new neurologic symptoms or with a patient who cannot be optimally evaluated clinically.

F. Known or new compression fracture noted on x-rays and/or CT, but additional information required for ONE of the following:

i. MRI needed to help distinguish osteoporotic, benign fracture from metastatic/myelomatous disease (if initial MRI is indeterminate in this setting, repeat MRI in 6 weeks may be approved).
ii. with new focal neurologic deficit
iii. to determine the position of fracture fragments.
iv. to assess union of the fracture when delayed or nonunion is suspected (CT is typically preferable).
v. prior to surgery/intervention/vertebral augmentation, when the MRI results may change treatment plan.

G. Multiple Sclerosis or other demyelinating/inflammatory processes, to include transverse myelitis, and acute disseminated encephalomyelitis (ADEM)---MRI of cervical and Thoracic spine is considered medically necessary (trial of conservative treatment not required) if any of the following are met:

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i. with findings suggestive of MS on recent brain MRI, and prior spinal imaging has not yet been completed.
ii. high clinical suspicion of MS, but the brain MRI results are inconclusive/indeterminate.
iii. MS is either known or suspected, and there are new or changing symptoms suggesting spinal cord involvement.
iv. to assess disease extent prior to initiating disease modification treatments.
v. prior to changing disease modification treatments, to establish a new baseline.
vi. for follow-up of known MS, within 6-12 months of initiating or changing treatment with disease modifying medications. vii. clinical symptoms suggestive of either transverse myelitis or neuromyelitis optica. viii. suspected or known pediatric demyelinating disease, to include acute disseminated encephalomyelitis.
ix. Clinical suspicion of Guillain-Barre Syndrome with non-diagnostic CSF studies and EMG/Nerve Conduction studies.

H. For evaluation of tumor /metastasis. For primary spinal tumor, for initial staging, or repeat exams with either:

i. follow-up within one year of active treatment, or for surveillance as suggested by NCCN.
ii. known tumor and new focal neurologic deficit or new signs/symptoms (increasing pain, lab/other CT/x-ray/bone scan findings) suggesting disease progression.

For Metastatic Tumor:

i. new focal neurologic deficit or new signs/symptoms (increasing pain,) OR
ii. lab/other CT/x-ray/bone scan findings suggesting disease progression OR iii. evidence of metastasis on bone scan or other imaging, and further clarification needed, OR
iv. known malignancy with new signs/symptoms suggesting metastatic disease, OR
v. for evaluation of suspected drop metastases or of leptomeningeal carcinomatosis.

I. Post-Operative spinal disorders---For clinical findings suggestive of CSF leak, or suspected post op infection, or for new or worsening symptoms/neurologic deficits after surgery. Routine post operative

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surveillance imaging, without symptoms, is considered not medically necessary, and requests for post operative imaging must document why the additional imaging is needed/requested.

J. Indeterminate findings on prior imaging AND:

i. initial, more definitive imaging is needed, OR
ii. one follow-up exam following an indeterminate MRI/CT to assess for interval change.

K. Suspected Infection (disc space infection, epidural abscess, spinal osteomyelitis), provided there are either abnormal signs/symptoms or laboratory findings (such as leukocytosis or elevated ESR/CRP) or suggestive alternate imaging. For follow-up of known infection with worsening symptoms/laboratory values, or to monitor post-operative results.

L. Spinal Dysraphism/Tethered Cord-- For initial imaging of known Arnold- Chiari syndrome, one time MRI Cervical, Thoracic, Lumbar spine is medically necessary, or for follow-up with new or changing signs/symptoms.

M. Suspected Myelopathy--If high clinical suspicion of myelopathy (such as unexplained Lhermitte’s or Babinski’s or Hoffmann’s signs), or unexplained limb hyperreflexia or unexplained bilateral motor weakness, or progressive worsening of symptoms, to include hand clumsiness, difficulty grasping objects, worsening balance/ambulation, diffuse numbness/tingling in bilateral hands, MRI of Cervical and Thoracic spine is considered medically necessary.

N. Suspected syringomyelia-- MRI cervical and thoracic is considered medically necessary, when syringomyelia is clinically suspected due to neurologic findings or due to predisposing conditions such as Chiari malformation, prior trauma, neoplasm, arachnoiditis, or to better characterize an abnormality/suspected syrinx seen on other imaging. Follow-up MRI is medically necessary with known syrinx and new/worsening signs/symptoms.

(If MRI cervical detects syrinx, then MRI brain and MRI Thoracic spine are

medically necessary to assess for inferior extent of syrinx and evaluate for

potential syringobulbia).

O. Scoliosis/Kyphosis—when the following are met:

a) plain radiographs have been obtained, AND
b) one of the following:

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i. needed for preoperative planning.
ii. with suspected underlying cord abnormalities (syrinx, diastematomyelia, tethered cord) or tumors, to include convex left thoracic curve, greater than 30-degree kyphosis. iii. with associated new or unexplained neurologic deficit. iv. child less than 10 years old with congenital or juvenile idiopathic scoliosis.

P. SCS Placement---MRI of thoracic spine is medically necessary, provided MRI of the thoracic spine has not been completed in the past 6 months.

Q. Pediatric Back Pain with documented vertebral anomalies (such as hemivertebra, hypoplasia, butterfly vertebra, congenital wedging).

R. Spasticity or increased muscle tone in the upper or lower extremities or gait abnormalities suspected to be related to myelopathy.

S. MRI Lumbar spine is medically necessary for suspected cauda equina syndrome, with severe back pain and ONE of the following:

i. saddle anesthesia of the pelvis,
ii. bilateral absent Achilles reflexes,
iii. new onset bowel/bladder dysfunction,
iv. absent anal and/or bulbocavernous reflexes

T. For pediatric known anorectal malformations, MRI lumbar is medically necessary, if either:

a) suspicious pediatric sacral dimples (i.e., deep or multiple dimples, at or above superior gluteal crease, larger than 5mm, or with associated cutaneous markers) if > 3 months old, OR
b) if less than 3 months old, ultrasound is the preferred imaging, and MRI lumbar is deemed medically necessary only if the ultrasound is indeterminate/inconclusive.

U. For preoperative evaluation/planning, provided there has not been a similar MRI in the past 6 months.

V. For evaluation of congenital vertebral defects (such as segmentation anomalies) if radiographs are nondiagnostic and results will impact treatment.

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W. MRI of the cervical spine is medically necessary to evaluate abnormalities of the craniocervical junction, provided there is an underlying high-risk condition.

In addition to the indications listed above, a trial of conservative treatment prior to MRI is not required with:

a) isolated back/neck pain in a pediatric population.
b) suspected atlantoaxial instability.
c) for evaluation of rheumatoid arthritis with neurologic signs/symptoms or subluxation detected on flexion/extension radiographs.

NOTE: The need for concurrent, similar studies, such as MRI and CT, require documentation of medical necessity for preoperative surgical planning, with requirement for both bony and soft tissue anatomic evaluation.

If MRI of the entire spinal cord is indicated, cervical and thoracic spine will be approved, but MRI of the lumbar spine will be considered not medically necessary, unless there is documentation of known or suspected low-lying conus medullaris. The conus typically ends at the L1 level and will be included in thoracic spine imaging.

For pre and postoperative planning/evaluation, MRI is typically preferable for evaluating the spinal cord, nerve roots, and for disc pathology and post-op infection, whereas CT is typically preferable for evaluating the bones, hardware complications, and to determine extent of fusion, or possible pseudoarthrosis.

If a combination request (for example MRI cervical AND thoracic spine) is requested, medical records must document why overlapping imaging is necessary, unless combination imaging is addressed as medically necessary within this medical guideline.

Requests for repeat MR imaging, after completing MR of the same anatomic site in the past 6 months, will be reviewed on a case-by-case basis. The most recent imaging reports must be submitted, and for the repeat exam to be approved as medically necessary, ONE of the following MUST be met:

a) documentation that the prior testing was inconclusive or with short-term follow-up imaging recommended. b) clinical documentation of progressive worsening of symptoms or new physical exam findings prompting the repeat imaging, and that patient management will be altered by the imaging results. c) interval surgery (with suspected complication) or significant new trauma to that anatomic region.

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Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.” A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, it will be considered not medically necessary.

D. For 3D Rendering, refer to 3D Rendering of MRI, CT, US Medical Guideline.

E. MRI of lumbar spine is considered not medically necessary for placement of a spinal cord stimulator (MRI of thoracic spine is considered medically necessary).

F. For evaluation of suspected myelopathy or multiple sclerosis (MS), MRI of the lumbar spine is considered not medically necessary, unless other than the Lumbar spine is being imaged for other reasons that meet the guideline under Indications of Coverage above.

G. Spinal imaging as a routine follow-up for MS, more frequent than every 1-2 years, is considered not medically necessary, unless there have been new or changing symptoms or changes made in disease modifying treatments.

H. Routine postoperative surveillance imaging, without clinical symptomatology, is considered not medically necessary.

I. Use of low field MRI for evaluation of the spine is considered experimental, investigational, unproven.

J. Magnetic resonance neurography for diagnosis of peripheral nerve disorders is considered experimental, investigational, and unproven.

K. MRI to evaluate spina bifida occulta is considered not medically necessary unless the patient is symptomatic and there is clinical concern for tethered cord.

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Documentation Required:

Prior authorization is required for all spinal MRI procedures. To obtain prior authorization, the requesting provider must submit the following information:

• A standard written order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.

• Medical record information (including continued need/use if applicable) and medical necessity.

• Correct coding for the service that meets all coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered. State mandates, laws or benchmark supersede this medical guideline.

Imaging is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

**All imaging related to cancer care, WPS uses NCCN as a primary reference.

Guideline Review History:

Implemented 01/01/24, 12/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 10/26/23, 11/21/24, 03/27/25, Q1 2026 Reviewed

10/26/23, 11/21/24, 03/27/25, Q1 2026 Revised 02/23/24 effective 04/23/24 Developed 10/26/23

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Codes
Code Description

72141 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without contrast material
72142 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; with contrast material(s)
72146 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material
72147 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; with contrast material(s)
72148 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material
72149 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; with contrast material(s)
72156 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical
72157 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material; followed by contrast material(s) and further sequences; thoracic
72158 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material; followed by contrast material(s) and further sequences; lumbar
S8042 Low-field magnetic resonance imaging (MRI)

Associated Codes A9573 Injection, Gadopiclenol, 1 ml
A9575 Injection, Gadoterate meglumine, 0.1 ml
A9577 Injection, Gadobenate Dimeflumine (Multihance), per ml
A9585 Injection Gadobutrol, 0.1 ml
J2405 Injection, ondansetron hydrochloride, per 1 mg
J2704 Injection, propofol, 10 mg
J3010 Injection, fentanyl citrate, 0.1 mg

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