Coverage Policy Manual
Policy #: 2004041
Category: Radiology
Initiated: June 2004
Last Review: September 2018
  Digital Motion X-ray (Cineradiography/Videoradiography) for Musculoskeletal Conditions

Description: Digital motion x-ray provides 2-D image sequences of a joint in motion.  However, images often suffer due to noise, exacerbated by the very low radiation dosage.  There are reports of digital motion x-ray studies of multiple joints but most articles address spine instability.  Variation in spinal motion of subjects in different age ranges requires care in the interpretation of these studies.   

Several articles have been written regarding evaluation for whiplash.  Van Goethem et al concluded the role of medical imaging in the evaluation of whiplash injuries remains to be determined.  Rodriguez et al states no imaging, physiological, or psychological study provides specific diagnostic criteria in the evaluation of patients with whiplash associated disorder.  Sizer et al states scientific literature has yet to confirm the validity of any specific imaging evaluation for diagnosis of neck pain.

In 1991 the Council on Diagnostic Imaging of the American Chiropractic Association, Inc., issued a position statement addressing videofluoroscopy in the evaluation of suspected intersegmental joint dysfunction which has not been adequately demonstrated by other methods and which has not responded to appropriate conservative management.  There is no comment on the use of videofluoroscopy for any other anatomical area.

Synonyms for digital motion x-ray include cineradiography, videoradiography, videofluoroscopy, and Fluoro video.  There is no specific code for the use of digital motion x-ray in musculoskeletal applications.  In the April 2004 issue of CPT Assistant a question was submitted asking if 76499 - unlisted diagnostic radiographic procedure, would be appropriate to bill a digital motion x-ray study.  The response: From a CPT coding perspective, it would be appropriate to report code 76120, cineradiography/videoradiography, except where specifically included, for the digital motion x-ray study procedure.   The AMA was asked to develop a code for this procedure in 2003 but the request was rejected due to lack of support from any specialty organization.

Policy/
Coverage:
Effective, June 2005
The use of digital motion x-ray for the evaluation of musculoskeletal conditions is not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without primary coverage criteria, the use of digital motion x-ray for the evaluation of musculoskeletal conditions is considered investigational.  Investigational services are an exclusion in the member certificate of coverage.

Rationale:
The current literature evaluating the clinical utility of dynamic spinal visualization techniques, including digital motion x-ray and cineradiography (videofluoroscopy) for the evaluation and assessment of the spine, is limited to a few studies involving very small numbers of participants (Hino, 1999) (Takayanagi, 2001) (Wong, 2004).  
 
The clinical utility of this technique has not been demonstrated. While reports have studied the correlation of this technique to disc degeneration (Fujiwara, 2000), no studies have evaluated the incremental value of this information compared to the standard evaluation. In addition, no studies have shown how the use of this information has an impact on or improves health outcomes.
 
Studies have shown that abnormalities in spinal motion are found in individuals with low back pain, particularly those with spondylolisthesis. However, the test does not always separate those with disease from those without disease (Okawa, 1998).  In addition, this technique continues to evolve.  Recent studies describe new computer-based approaches (Wong, 2006).  
 
At this time, the published data are not sufficient to support the use of digital motion x-rays or cineradiography/videofluoroscopy of the spine for any indication.
 
2007-2008 Update
A search of the MEDLINE database for the period of January 2007 through January 2008 did not identify any evidence that would alter the conclusions reached above. The current literature consists predominantly of assessment of spine kinetics in patients with neck or back pain. For example, one study (164 patients) used kinetic magnetic resonance imaging to characterize the effect of progressive disc degeneration on motion of the cervical spine (Miyazaki, 2008).  Another study compared 20 patients with lower back pain to 20 healthy controls in order to provide construct validity for a clinical prediction rule that would identify patients likely to benefit from stabilization exercises (Teyhen, 2007).  No evidence was identified to indicate that clinical use of dynamic visualization improves health outcomes.
 
2009 Update
A search of the MEDLINE database did not reveal any new information that would prompt a change in the coverage statement.
 
2012 Update
As of the most recent literature update through July 2012, the evidence on dynamic spinal visualization remains predominantly of comparisons of spine kinetics in patients with neck or back pain with healthy controls.  Ahmadi and colleagues used digital videofluoroscopy to compare 15 patients with lower back pain and 15 controls to assist in identifying better criteria for diagnosis of lumbar segmental instability (Ahmadi, 2009). Another study from 2009 used dynamic fluoroscopy to assess lateral flexion in 30 healthy controls, noting that data pooling from multiple studies would be needed to establish a complete database of reference limits from asymptomatic individuals (Mellor, 2009).
 
A feasibility study of dynamic magnetic resonance imaging (MRI) was reported in 2012 (Gerigk, 2012).  This study used a prototype of the NeuroSwing positioning device and evaluated cervical spine kinematics in 32 patients who had previously undergone anterior cervical discectomy and fusion (ACDF). The quality of images was considered to be adequate, although there was some artifact from the titanium implants used in ACDF.
 
Summary
The evidence at this time is insufficient to evaluate the effect on health outcomes of digital motion x-rays, cineradiography/videofluoroscopy, or dynamic MRI of the spine for any indication.
 
2013 Update
A literature search using the MEDLINE database through August 2013 did not reveal any new information that would prompt a change in the coverage statement.
 
2014 Update
A literature search conducted through August 2014 did not reveal any new information that would prompt a change in the coverage statement.
 
2015 Update
A literature search conducted through August 2015 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
 
A literature search conducted using the Medline database through August 2017. There were no new randomized controlled trials identified. There was no information identified that would prompt a change in the coverage statement.
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2018. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
76120Cineradiography/videoradiography, except where specifically included
76499Unlisted diagnostic radiographic procedure

References: Ahmadi A, Maroufi N, Behtash H et al.(2009) Kinematic analysis of dynamic lumbar motion in patients with lumbar segmental instability using digital videofluoroscopy. Eur Spine J 2009; 18(11):1677-85.

Cooper R, Cardan C, Allen R.(2001) Computer visualisation of the moving human lumbar spine. Comput Biol Med 2001; 31:451-69.

Gerigk L, Bostel T, Hegewald A et al.(2012) A et al. Dynamic magnetic resonance imaging of the cervical spine with high-resolution 3-dimensional T2-imaging. Clin Neuroradiol 2012; 22(1):93-9.

Grip H, Ohberg F, et al.(2003) Classification of neck movement patterns related to whiplash-associated disorders using neural networks. IEEE Trans Inf Technol Biomed 2003; 7:412-8.

Hino H, Abumi K, Kanayama M et al.(1999) Dynamic motion analysis of normal and unstable cervical spines using cineradiography. An in vivo study. Spine 1999; 24(2):163-8.

Kondo T, Hashimoto J, et al.(2004) Radiographic analysis of the acromion in the loose shoulder. J Shoulder Elbow Surg 2004; 13:404-9.

Lee SW, Wong KW, et al.(2002) Development and validation of a new technique for assessing lumbar spine motion. Spine 2002; 27:E215-20.

Mellor FE, Muggleton JM, Bagust J et al.(2009) Midlumbar lateral flexion stability measured in healthy volunteers by in vivo fluoroscopy. Spine (Phila Pa 1976) 2009; 34(22):E811-7.

Moeine SM, Lemons JE, et al.(1996) Investigation of video techniques for dynamic measurements of relative vertebral-body motion in vitro. Biomed Instrum Technol 1996; 30:62-70.

Muggleton JM, Allen R.(1997) Automatic location of vertebrae in digitized videofluoroscopic images of the lumbar spine. Med Eng Phys 1997; 19:77-89.

Okawa A, Shinomiya K, et al.(1998) Dynamic motion study of the whole lumbar spine by videofluoroscopy. Spine 1998; 23:1743-9.

Okawa A, Shinomiya K, et al.(1998) Dynamic motion study of the whole lumbar spine by videofluoroscopy. Spine 1998; 23:1743-9.

Ovadia D, Steinberg EL, et al.(2002) Whiplash injury--a retrospective study on patients seeking compensation. Injury 2002; 33:569-73.

Rodriquez AA, Barr KP, Burns SP.(2004) Whiplash: pathophysiology, diagnosis, treatment, and prognosis. Muscle Nerve 2004; 29; 768-81.

Sizer PS, Poorbaugh K, Phelps V.(2004) Whiplash associated disorders: Pathomechanics, diagnosis, and management. Pain Practice 2004; 4:249.

Takayanagi K, Takahashi K, Yamagata M et al.(2001) Using cineradiography for continuous dynamic-motion analysis of the lumbar spine. Spine 2001; 26(17):1858-65.

Teyhen DS, Flynn TW, Childs JD et al.(2007) Arthrokinematics in a subgroup of patients likely to benefit from a lumbar stabilization exercise program. Phys Ther 2007; 87(3):313-25.

Teyhen DS, Flynn TW, Childs JD et al.(2008) Kinematic analysis of the relationship between the grade of disc degeneration and motion unit of the cervical spine. Spine 2008; 33(2):187-93.

Tong C, Barest G.(2003) Approach to imaging the patient with neck pain. J Neuroimaging 2003; 13:5-16.

Van Goethem JW, Ozsarlak O, Parizel PM.(2003) Cervical spine fractures and soft tissue injuries. JBR-BTR 2003; 86:230-4.

Wong KW, Leong JC, Chan MK et al.(2004) The flexion-extension profile of lumbar spine in 100 healthy volunteers. Spine 2004; 29(15):1636-41.

Wong KW, Leong JC, et al.(2004) The flexion-extension profile of lumbar spine in 100 healthy volunteers. Spine 2004; 29:1636-41.

Wong KW, Luk KD, Leong JC et al.(2006) Continuous dynamic spinal motion analysis. Spine 2006; 31(4):414-9.

Zheng Y, Nixon MS, Allen R.(2003) Lumbar spine visualisation based on kinematic analysis from videofluoroscopic imaging. Med Eng Phys 2003; 25:171-9.

Zheng Y, Nixon MS, Allen R.(2004) Automated segmentation of lumbar vertebrae in digital videofluoroscopic images. IEEE Trans Med Imaging 2004; 23:45-52.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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