Coverage Policy Manual
Policy #: 2006027
Category: Radiology
Initiated: July 2006
Last Review: October 2018
  Dynamic Spinal Visualization and Vertebral Motion Analysis

Description: Computerized x-ray analysis for the evaluation of spinal subluxation involves the use of specialized software to objectively analyze the biomechanical and misalignment improprieties related to vertebral subluxation.  Static radiographs are digitized or scanned into the computer, and digital radiographic software analyses the radiographs.  Lines of mensuration (measurement of geometric figures, including length, angle measurement, area, and volume) may be drawn by the computerized radiographic digitization procedures.  Motion analysis is usually not part of this procedure (see Digital Motion X-ray Policy for motion evaluation).   

There is no specific code describing digitization of static (plain) films or the computer analysis that might be done after digitization is done.  Any analysis would be considered a component of the interpretation of the initial film.

Policy/
Coverage:
Effective October 2018
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Dynamic spinal visualization does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For members with contracts without primary coverage criteria, dynamic spinal visualization is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Vertebral motion analysis does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For members with contracts without primary coverage criteria, vertebral motional analysis is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective Prior to October 2018
 
Spinal visualization using digitization of spinal x-rays and computerized analysis of the back or spine is not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without primary coverage criteria, digitization of spinal x-rays and computerized analysis of the back or spine is not covered because payment is limited to the established Allowance or Allowable Charge as set by the Company.

Rationale:
The procedure is not covered because payment is limited to the less-costly and equally effective manual process commonly employed be reviewing professionals.  If x-rays are otherwise a covered benefit, payment will be made for the x-rays under established Allowance or Allowable Charge as set by the Company.  Excess charges based on the computerization of the process will not be separately compensated.  The Allowable Charge includes payment for both a professional and a technical component, thereby fully compensating for the covered x-ray, whether the professional analysis is facilitated by hand or by the computer. Additionally, participating providers agree to accept the Company's established Allowance as payment in full for the service rendered, and may not bill for excess charges above the Allowance.
 
2010 Update
A review of the literature has been conducted through August 2010.  There was no new literature identified that would prompt a change in the coverage statement.
 
2013 Update
A search of the MEDLINE database through September 2013 was conducted. There was no new literature identified that would prompt a change in the coverage statement.
 
 
2015 Update
A literature search conducted through September 2015 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted through September 2017 did not reveal any new information that would prompt a change in the coverage statement.    
 
2018 Update
A literature search was conducted through September 2018.  The key identified literature is summarized below.
 
VERTEBRAL MOTION ANALYSIS
 
Clinical Context and Test Purpose
The purpose of vertebral motion analysis (VMA) is to determine whether the abnormal movement of the spine contributes to neck or back pain. This would inform clinical decision making about the appropriate intervention, either physical therapy or surgery. VMA might also be used to assess the success of fusion.
 
The question addressed in this evidence review is: Does the use of VMA provide additional information beyond that obtained with conventional imaging technology and does this additional information improve health outcomes?
 
The following PICOTS were used to select literature relevant to the review.
 
Patients
The relevant population of interest is individuals who are being evaluated for back or neck pain and are being considered for standard flexion/extension radiographs.
 
Interventions
The test being considered is VMA.
 
Comparators
The following tests are currently being used to make decisions about managing abnormal movement contributing to back and neck pain: conventional radiography and MRI.
 
Outcomes
The outcomes of interest are whether VMA leads to new findings and whether these findings improve health outcomes, including pain and function.
 
Timing
Short-term outcomes after physical therapy or surgery.
 
Setting
VMA is administered in an outpatient setting.
 
Technically Reliable
Assessment of technical reliability focuses on specific tests and operators and requires review of unpublished and often proprietary information. Review of specific tests, operators, and unpublished data are outside the scope of this evidence review and alternative sources exist. This evidence review focuses on the clinical validity and clinical utility.
 
Clinically Valid
A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).
 
Cheng et al and Yeager et al reported that VMA decreased variability in the measurement of lumbar spinal movement compared with a digitized manual technique (Cheng, 2016; Yeager, 2014). Diagnostic performance of VMA was reported by Davis et al in a retrospective study of 509 symptomatic patients and 73 asymptomatic participants (Davis, 2015). The comparator was rotational and translational movement from flexion/extension radiographs. The investigators considered instability in symptomatic patients to be true-positive and instability in asymptomatic participants as false-positive, leading to reported differences in diagnostic accuracy between standard flexion/extension radiographs and VMA. In the absence of a true reference standard, the interpretation of this study is limited.
 
Clinically Useful
A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.
 
Direct Evidence
Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from RCTs.
 
No RCTs were identified that support the clinical utility of VMA in this population.
 
Chain of Evidence
Indirect evidence on clinical utility rests on clinical validity. If the evidence is insufficient to demonstrate test performance, no inferences can be made about clinical utility.
 
Because the clinical validity of VMA has not been established for this indication, a chain of evidence cannot be constructed.
 
Section Summary: Vertebral Motion Analysis
Three studies with overlapping authors have been identified on VMA. These studies have reported that
VMA reduces variability in the measurement of rotational and translational spine movement compared with standard flexion/extension radiographs. One study reported an improvement in diagnostic accuracy compared with flexion/extension radiographs, but the interpretation of this study is limited by the lack of a true reference standard.
 
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/video fluoroscopy, or dynamic magnetic resonance imaging of the spine and neck. The available studies compare spine kinetics in patients who had neck or back pain with that in healthy controls. No literature was identified on the diagnostic accuracy of dynamic visualization in a relevant patient population. No evidence was identified on the effect of this technology on symptoms or functional outcomes. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
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 the effects of the technology on health outcomes.

CPT/HCPCS:
76499Unlisted diagnostic radiographic procedure

References: Cheng B, Castellvi AE, Davis RJ, et al.(2016) Variability in flexion extension radiographs of the lumbar spine: a comparison of uncontrolled and controlled bending. Int J Spine Surg. Jul 2016;10:20. PMID 27441178

Gitlin JN, Scott WW, et al.(2002) Interpretation accuracy of a CCD film digitizer. J Digit Imaging 2002; 15 Suppl 1:57-63.

Kluba T, Schafer J, et al.(2006) Prospective randomized comparisons of radiation exposure from full spine radiographs obtained in three different techniques. Eur Spine J 2006; 15:752-6.

Schuler TC, Subach BR, et al.(2004) Segmental lumbar lordosis: manual versus computer-assisted measurement using seven different techniques. J Spinal Disord Tech 2004; 17:372-9.

Yeager MS, Cook DJ, Cheng BC.(2014) Reliability of computer-assisted lumbar intervertebral measurements using a novel vertebral motion analysis system. Spine J. Feb 1 2014;14(2):274-281. PMID 24239805


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.
CPT Codes Copyright © 2019 American Medical Association.