Discography Form

MEDICAL COVERAGE POLICY SERVICE: Discography Policy Number: 072 Effective Date: 03/01/2026 Last Review: 02/26/2026 Next Review: 02/26/2027 Page 1 of 5 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy. SERVICE: Discography PRIOR AUTHORIZATION: Required POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for details. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) or LCD (Local Coverage Determination). If there are no applicable NCD or LCD criteria, use the criteria set forth below. For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. BSWHP considers lumbar discography medically necessary. See InterQual criteria. BSWHP considers discography, as part of an injection procedure for chemonucleolysis, medically necessary as determined by eviCore® medical review (CPT code 62292). BSWHP considers cervical and thoracic discography, either provocative or for analysis and mapping (see CPT codes below), experimental and investigational and NOT medically necessary. BSWHP considers lumbar discography performed with the use of material other than contrast experimental and investigational and NOT medically necessary. BSWHP considers a lumbar discography procedure done in the presence of any red flag condition as NOT medically necessary.

MEDICAL COVERAGE POLICY SERVICE: Discography Policy Number: 072 Effective Date: 03/01/2026 Last Review: 02/26/2026 Next Review: 02/26/2027 Page 2 of 5 BACKGROUND:
Discography is a procedure in which contrast is injected, under fluoroscopy, into the nucleus of a disc thought to be the cause of a patient's low back pain. Discography is considered positive if it demonstrates an annular disruption verified by contrast coming through tears in disc, and if it reproduces the patient's usual back pain. The value of this test is controversial because of the absence of a clearly defined “gold-standard” reference test, multiple complications, and difficultly in identifying patients in whom interventions showed better outcomes. Discography has a high false positive rate, even with methods utilized to reduce this, and has a significant false positive rate in asymptomatic individuals. Possible complications of discography include discitis, headache, worsening of chronic back pain, accelerated disc degeneration, and disc herniation. American Society of Interventional Pain Physicians (ASIPP): The ASIPP issued an update of its evidence-based guidelines for interventional techniques in chronic spinal pain (2013). In regard to the clinical utility of discography, the ASIPP issued the following recommendations:  Provocation discography continues to be controversial with respect to diagnostic accuracy and its impact on surgical volume.  Proponents of discography claim that the rationale is well established, and discography is helpful in patients with low back pain (LBP) to acquire information about the structure and sensitivity of their lumbar discs and to make informed decisions about treatment and modifications of activity.  Opponents of discography contend that escalating numbers of unnecessary fusions have been performed in the United States each year for indications of discogenic pain.  Discography is an invasive diagnostic test that should only be applied to patients with chronic LBP in whom one suspects a discogenic etiology and an appropriate treatment is available.  To be valid, provocation discography must be performed utilizing strict criteria of having concordant pain in 1 disc with at least 2 negative control discs.  In the ASIPP management algorithm for chronic LBP, discography is suggested following clinical evaluation indicating that facet joint blocks or sacroiliac joint blocks were negative. RED FLAG CONDITIONS, where discography would not be medically necessary and patient would require emergent surgical management.  Suspected unstable fractures of the spine which may be evidenced by a history of a recent fall or injury, and major motor weakness of a limb, or progressive neurological deficits, or bladder or bowel dysfunction  History of cancer with suspicion of metastatic spread which may be evidenced by major motor weakness of a limb, or pain which increases at night or at rest, or progressive neurological deficits, or bladder or bowel dysfunction, or unexplained weight loss of more than 10 pounds in 6 weeks.  Infection with suspicion of an epidural abscess/discitis which may be evidenced by progressive

MEDICAL COVERAGE POLICY SERVICE: Discography Policy Number: 072 Effective Date: 03/01/2026 Last Review: 02/26/2026 Next Review: 02/26/2027 Page 3 of 5 neurological deficits, or fever of 100.4 for more than 48 hours, and C-reactive protein >10 mg/L, or recent (within 2 weeks) interventional spine procedures, or ESR >20 mm/hr, or immunocompromised (either immunodeficiency from any cause or IV drug abuse)  Cauda equina syndrome which may be evidenced by bladder or bowel dysfunction, or saddle anesthesia, or progressive neurological deficits MANDATES: There are no mandated benefits or regulatory requirements for coverage for this service. CODES: Important note: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Covered 62292 - Injection procedure for chemo nucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar 62290 - Injection procedure for discography, each level: lumbar
72295 - Discography, lumbar, radiological supervision and interpretation
CPT Not Covered 62291 - Injection procedure for discography, each level; cervical or thoracic 72285 - Discography, cervical or thoracic, radiological supervision and interpretation ICD-10-codes covered if selection criteria are met M54.50-M54.59 Low back pain M54.30 - M54.32 Sciatica M96.1 Post laminectomy syndrome M51.46-M51.47 Schmorl’s nodes, lumbar/lumbosacral region M51.36-M51.37 other intervertebral disc degeneration, lumbar/lumbosacral M51.26-M51.27 Other intervertebral disc displacement, lumbar/lumbosacral
M51.16-17 Spondylosis with myelopathy M51.06-M51.07 Intervertebral disc disorder w/ myelopathy, lumbar M48.061-M48.07 Spinal stenosis lumbar/lumbosacral M47.816-M47.817 L/LS spondylosis w/o myelopathy M47.16-M47.17 Other spondylosis w/ myelopathy L/LS region M46.46-M46.47 Other /unsp disc disorder/LS region M43.06-M43.07 Acquired Spondylisthesis POLICY HISTORY: Status Date Action New 6/1/2010 New policy Reviewed 12/6/2011 Reviewed. Reviewed 11/29/2012 Major revision. Determined to be investigational/experimental. Reviewed 11/14/2013 Changes to overview.

MEDICAL COVERAGE POLICY SERVICE: Discography Policy Number: 072 Effective Date: 03/01/2026 Last Review: 02/26/2026 Next Review: 02/26/2027 Page 4 of 5 Reviewed 11/6/2014 No changes. Reviewed 10/22/2015 No changes. Reviewed 11/17/2016 No changes Reviewed 09/26/2017 No changes Reviewed 07/17/2018 Removed 62292 from “not covered” (to be managed by eviCore®) Reviewed 09/26/2019 Added clarification. Reviewed 10/24/2020 No changes Reviewed 11/24/2021 No changes Reviewed 12/1/2022 No changes Reviewed 12/29/2023 Formatting changes, added hyperlink to TMPPM, beginning and ending note sections updated to align with CMS requirements and business entity changes Reviewed 02/10/2025 Revised medically necessary statement to clarify indications apply to lumbar discography only under certain conditions, added CPT codes that may be covered Updated 08/11/2025 Removed, “Medicare NCD or LCD specific InterQual criteria may be used when available.” Updated 02/26/2026 Updated References REFERENCES:
The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence surrounding discography and may modify this policy at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available, and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

1. Carragee EJ, Lincoln T, Parmar VS, Alamin T. A gold standard evaluation of the "discogenic pain" diagnosis as determined by provocative discography. Spine (Phila Pa 1976) 2006; 31:2115.
2. Cohen SP, Larkin TM, Barna SA, et al. Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles. Reg Anesth Pain Med 2005; 30:163.
3. Carragee EJ, Don AS, Hurwitz EL, et al. 2009 ISSLS Prize Winner: Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine (Phila Pa 1976) 2009; 34:2338.
4. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34:1066.
5. Bradley WG Jr, Seidenwurm DJ, Brunberg JA, et al. Low back pain. American College of Radiology (ACR), 2005. Available at: www.guideline.gov/summary/summary.aspx?doc_id=8599#s24 (Accessed on October 11, 2011).

MEDICAL COVERAGE POLICY SERVICE: Discography Policy Number: 072 Effective Date: 03/01/2026 Last Review: 02/26/2026 Next Review: 02/26/2027 Page 5 of 5

6. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478. Note: (The guidelines recommend the use of imaging with MRI or CT (not discography) to evaluate low back pain only when severe or progressive neurological deficits are present, when serious underlying conditions are suspected, or when surgery or epidural steroid injection is considered. Also, the guidelines recommend several conservative approaches for acute or chronic pain and suggest invasive techniques only for pain that does not respond to the recommended conservative approaches but do not discuss any particular invasive measure)
7. Carragee EJ, Tanner CM, Yang B, Brito JL, Truong T. False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine. 1999;24(23):2542-2547. Cited in: Wolfer LR, Derby R, Lee JE, Lee SH. Systematic review of lumbar provocation discography in asymptomatic subjects with a meta- analysis of false-positive rates. Pain Physician. 2008;11(4):513-538.
8. Xi MA, Tong HC, Fahim DK, Perez-Cruet M. Using provocative discography and computed tomography to select patients with refractory discogenic low back pain for lumbar fusion surgery. Cureus. 2016;8(2):e514.
9. Manchikanti L, Hirsch JA. An update on the management of chronic lumbar discogenic pain. Pain Manage. 2015;5(5):373-
11. Is Discography Associated With a Higher Rate of Re-operation for Disc-Related Pain 10 to 20 Years Later?. Spine.2025.Ohnmeiss DD. Courtois EC, Guyer RD, et al. Note:  Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company.  Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan.  RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs; and FirstCare CHIP is offered through FirstCare in the Lubbock Service Area.