195 Form

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Medical Policy Dynamic Spinal Visualization and Vertebral Motion Analysis
Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 195

BCBSA Reference Number: 6.01.46 (For Plan internal use only) NC/LCD: NA

Related Policies
None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members The use of dynamic spinal visualization is considered INVESTIGATIONAL.

Vertebral motion analysis is considered INVESTIGATIONAL. Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes
CPT codes: Code Description 76120 Cineradiography/videoradiography, except where specifically included 76125 Cineradiography/videoradiography to complement routine examination

DESCRIPTION Flexion/Extension Radiography Dynamic spinal visualization and vertebral motion analysis are proposed for individuals who are being evaluated for back or neck pain and are being considered for standard flexion/extension radiographs. Flexion/extension radiographs may be performed with a passive external force or by the patient's own movement. Typically, radiographs are taken at the end ranges of flexion and extension and the intervertebral movements (rotation and translation) are measured to assess spinal instability. Flexion/extension radiographs may be used to assess radiographic instability in order to diagnose and determine the most effective treatment (eg, physical therapy, decompression, or spinal fusion) or to assess the efficacy of spinal fusion.

Dynamic Spinal Visualization

Digital Motion X-Ray Most spinal visualization technologies use x-rays to create images either on film, video monitor, or computer screen. Digital motion x-ray involves the use of film x-ray or computer-based x-ray "snapshots" taken in sequence as a patient moves. Film x-rays are digitized into a computer for manipulation, while computer- based x-rays are automatically created in a digital format. Using a computer program, the digitized snapshots are then sequenced and played on a video monitor, creating a moving image of the inside of the body. This moving image can then be evaluated by a physician alone or by using computer software that evaluates several aspects of the body's structure, such as intervertebral flexion and extension, to determine the presence or absence of abnormalities.

Videofluoroscopy and Cineradiography Videofluoroscopy and cineradiography are different names for the same procedure, which uses fluoroscopy to create real-time video images of internal structures of the body. Unlike standard x-rays, which take a single picture at 1 point in time, fluoroscopy provides motion pictures of the body. The results of these techniques can be displayed on a video monitor as the procedure is being conducted, as well as recorded, to allow computer analysis or evaluation at a later time. Like digital motion x-ray, the results can be evaluated by a physician alone or with the assistance of computer software.

Dynamic Magnetic Resonance Imaging Dynamic magnetic resonance imaging (MRI) is also being developed to image the cervical spine. This technique uses an MRI-compatible stepless motorized positioning device and a real-time true fast imaging with steady-state precession sequence to provide passive kinematic imaging of the cervical spine. The quality of the images is lower than a typical MRI sequence but is proposed to be adequate to observe changes in the alignment of vertebral bodies, the width of the spinal canal, and the spinal cord. Higher- resolution imaging can be performed at the end positions of flexion and extension.

Vertebral Motion Analysis Vertebral motion analysis systems like the KineGraph VMA (Vertebral Motion Analyzer) provide assisted bending with fluoroscopic imaging and computerized analysis. The device uses facial recognition software

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to track vertebral bodies across the images. Proposed benefits of the vertebral motion analysis are a reduction in patient-driven variability in bending and assessment of vertebral movement across the entire series of imaging rather than at the end range of flexion and extension.

Summary
Description Dynamic spinal visualization is a general term addressing different imaging technologies that simultaneously visualize spine (vertebrae) movements and external body movement. Vertebral motion analysis uses similar imaging as dynamic spinal visualization, with the addition of controlled movement and computerized tracking. These technologies have been proposed for the evaluation of spinal disorders including neck and back pain.

Summary of Evidence For individuals who have neck or back pain who receive dynamic spinal visualization, the evidence includes comparative trials. Relevant outcomes are test accuracy, symptoms, and functional outcomes. Techniques include digital motion x-rays, cineradiography/videofluoroscopy, or dynamic magnetic resonance imaging (MRI) of the spine and neck. Most available studies compare spine kinetics in patients who had neck or back pain with spine kinetics in healthy controls. In a feasibility study of 21 patients examining dynamic MRI for the detection of spondylolithesis, 3 dynamic MRI protocols demonstrated sensitivities of 68.8% to 78.6% when compared to standard flexion-extension radiographs. No evidence was identified on the effect of this technology on symptoms or functional outcomes. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have back or neck pain who receive vertebral motion analysis, the evidence includes comparisons to standard flexion/extension radiographs. Relevant outcomes are test accuracy, symptoms, and functional outcomes. These studies reported that vertebral motion analysis reduces variability in measurement of rotational and translational spine movement compared with standard flexion/extension radiographs. Whether the reduction in variability improves diagnostic accuracy or health outcomes is uncertain. The single study that reported on diagnostic accuracy lacked a true criterion standard, limiting interpretation of findings. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 1/2026 Annual policy review. References updated. Policy statements unchanged. 11/2024 Annual policy review. Policy updated with literature review through August 5, 2024; references added. Policy statements unchanged. 11/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 11/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2019

Annual policy review. New investigational indications described. Vertebral Motion Analysis added to title. Effective 2/1/2019. 11/2015 Added coding language. 12/2013 Annual policy review. New references added. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
6/2011 Reviewed - Medical Policy Group – Orthopedics, Rehabilitation and Rheumatology.

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No changes to policy statements. 1/2011 Reviewed - Medical Policy Group – Neurology and Neurosurgery. No changes to policy statements. 7/2010 Reviewed - Medical Policy Group – Orthopedics, Rehabilitation and Rheumatology. No changes to policy statements.
6/1/2010 Medical Policy 195 issued describing on going non-coverage. Effective 6/1/2010.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Xu N, Wang S, Yuan H, et al. Does Dynamic Supine Magnetic Resonance Imaging Improve the Diagnostic Accuracy of Cervical Spondylotic Myelopathy? A Review of the Current Evidence. World Neurosurg. Apr 2017; 100: 474-479. PMID 28130164
2. Teyhen DS, Flynn TW, Childs JD, et al. Arthrokinematics in a subgroup of patients likely to benefit from a lumbar stabilization exercise program. Phys Ther. Mar 2007; 87(3): 313-25. PMID 17311885
3. Ahmadi A, Maroufi N, Behtash H, et al. Kinematic analysis of dynamic lumbar motion in patients with lumbar segmental instability using digital videofluoroscopy. Eur Spine J. Nov 2009; 18(11): 1677-85. PMID 19727854
4. Walter WR, Alizai H, Bruno M, et al. Real-time dynamic 3-T MRI assessment of spine kinematics: a feasibility study utilizing three different fast pulse sequences. Acta Radiol. Jan 2021; 62(1): 58-66. PMID 32233646
5. Hino H, Abumi K, Kanayama M, et al. Dynamic motion analysis of normal and unstable cervical spines using cineradiography. An in vivo study. Spine (Phila Pa 1976). Jan 15 1999; 24(2): 163-8. PMID 9926388
6. Takayanagi K, Takahashi K, Yamagata M, et al. Using cineradiography for continuous dynamic- motion analysis of the lumbar spine. Spine (Phila Pa 1976). Sep 01 2001; 26(17): 1858-65. PMID 11568694
7. Wong KW, Leong JC, Chan MK, et al. The flexion-extension profile of lumbar spine in 100 healthy volunteers. Spine (Phila Pa 1976). Aug 01 2004; 29(15): 1636-41. PMID 15284509
8. Huneidi M, Jankowski PP, Bouyer B, et al. Contribution of MRI and imaging exams in the diagnosis of lumbar pseudarthrosis. Orthop Traumatol Surg Res. May 2025; 111(3): 103817. PMID 38246489
9. Shin JJ, Yoo SJ, Kim TW, et al. Radiological and Clinical Significance of Cervical Dynamic Magnetic Resonance Imaging for Cervical Spondylotic Myelopathy. Neurospine. Jun 2024; 21(2): 443-454. PMID 38955522
10. Cheng B, Castellvi AE, Davis RJ, et al. Variability in Flexion Extension Radiographs of the Lumbar Spine: A Comparison of Uncontrolled and Controlled Bending. Int J Spine Surg. 2016; 10: 20. PMID 27441178
11. Yeager MS, Cook DJ, Cheng BC. Reliability of computer-assisted lumbar intervertebral measurements using a novel vertebral motion analysis system. Spine J. Feb 01 2014; 14(2): 274-81. PMID 24239805
12. Davis RJ, Lee DC, Wade C, et al. Measurement Performance of a Computer Assisted Vertebral Motion Analysis System. Int J Spine Surg. 2015; 9: 36. PMID 26273554