Description

Fluoroscopy is a type of radiographic imaging that shows the movement of a body part or movement of a contrast agent through the body. When used for musculoskeletal indications, it may be utilized to evaluate the entire spine, the movement of joints and other areas of the skeletal system. In videofluoroscopy (also known as cineradiography), fluoroscopic imaging is recorded to allow for repeated viewing at varying speeds, purportedly to aid in determining the area of joint dysfunction.

Digital motion x-rays are screen-film or computer-based snapshots taken in sequence as the individual moves through various positions. The digitized images are ordered sequentially using a computer program to simulate a moving image of the inside of the body.

Dynamic visualization describes several different imaging techniques including videofluoroscopy, vertebral motion analysis and digital motion x-ray. Vertebral motion analysis uses imaging similar to dynamic visualization with the addition of controlled movement and computerized tracking analysis.

Dynamic (kinematic) or upright magnetic resonance imaging (MRI) purportedly provides images of the spine under daily living or weight-bearing conditions. A vertically open configuration MRI enables sitting or standing during image capture. Position changes, such as flexion and extension of the neck or back can also be viewed.

Coverage Determination

Humana members may NOT be eligible under the Plan for the following imaging techniques for musculoskeletal indications:

• Digital motion x-ray; OR
• Dynamic MRI; OR
• Dynamic visualization; OR
• Flexion-extension MRI; OR
• Positional, standing, upright or weight-bearing MRI; OR
• Vertebral motion analysis; OR
• Videofluoroscopy (cineradiography)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about musculoskeletal conditions may be found from the following websites:

• American Academy of Orthopaedic Surgeons
• National Library of Medicine

Medical Alternatives

Alternatives to videofluoroscopy and dynamic MRI include, but may not be limited to, the following:

• Computed tomography (CT) scan
• MRI
• Screen-film radiography (x-ray)

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for services rendered.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications

Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0327-015
Page: 4 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

CPT® Code(s)

• 76120 Cineradiography/videoradiography, except where specifically included
  Not Covered if used to report any imaging techniques for musculoskeletal indications outlined in Coverage Determination section

HCPCS Code(s)

• No code(s) identified

Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications

Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0327-015
Page: 5 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References

• American College of Radiology (ACR). ACR Appropriateness Criteria. Suspected spine trauma. https://www.acr.org. Published 1999. Updated 2018. Accessed August 11, 2023.
• American College of Radiology (ACR). ACR-ASNR-SCBT-MR practice parameter for the performance of magnetic resonance imaging (MRI) of the adult spine. https://www.acr.org. Published 2001. Updated 2018. Accessed August 11, 2023.
• American College of Radiology (ACR). ACR-ASNR-SPR practice parameter for the performance of magnetic resonance imaging (MRI) of the head and neck. https://www.acr.org. Published 2002. Updated 2018. Accessed August 11, 2023.

• American College of Radiology (ACR). ACR-ASNR-SPR practice parameter for the performance of magnetic resonance imaging (MRI) of the pediatric spine. https://www.acr.org. Published 2019. Accessed August 11, 2023.
• Council on Chiropractic Practice (CCP). Clinical Practice Guidelines. Subluxation chiropractic practice. 4th ed. https://www.ccp-guidelines.org. Published 2013. Accessed August 11, 2023.
• ECRI Institute. Clinical Evidence Assessment. Dynamic spinal visualization for assessing lumbar spine abnormalities. https://www.ecri.org. Published July 27, 2023. Accessed August 10, 2023.
• ECRI Institute. Hotline Response (ARCHIVED). Upright magnetic resonance imaging (MRI) for diagnosing spine-related pain. https://www.ecri.org. Published December 15, 2004. Updated July 17, 2012. Accessed August 10, 2023.
• Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications
  Effective Date: 09/28/2023
  Revision Date: 09/28/2023
  Review Date: 09/28/2023
  Policy Number: HUM-0327-015
  Page: 6 of 6
• Hayes, Inc. Medical Technology Directory (ARCHIVED). Upright magnetic resonance imaging for diagnosis of spinal disorders. https://evidence.hayesinc.com. Published September 4, 2014. Updated August 21, 2018. Accessed August 10, 2023.
• MCG Health. Lower extremity MRI. 27th edition. https://www.mcg.com. Accessed August 7, 2023.
• North American Spine Society (NASS). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of degenerative lumbar spondylolisthesis. 2nd ed. https://www.spine.org. Published 2014. Accessed August 11, 2023.
• North American Spine Society (NASS). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of low back pain. https://www.spine.org. Published 2020. Accessed August 11, 2023.
• UpToDate, Inc. Evaluation and initial management of cervical spinal column injuries in adults. https://www.uptodate.com. Updated July 2023. Accessed August 11, 2023.
• UpToDate, Inc. Imaging techniques for evaluation of the painful joint. https://www.uptodate.com. Updated July 2023. Accessed August 11, 2023.
• UpToDate, Inc. Lumbar spinal stenosis: pathophysiology, clinical features and diagnosis. https://www.uptodate.com. Updated July 2023. Accessed August 11, 2023.
• UpToDate, Inc. Overview of acute wrist injuries in children and adolescents. https://www.uptodate.com. Updated July 2023. Accessed August 11, 2023.
• US Department of Veterans Affairs (VA). VA/DoD Clinical Practice Guideline. The non-surgical management of hip and knee osteoarthritis. https://www.va.gov. Published July 2020. Accessed August 11, 2023.