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Medical Policy: 06.01.02
Original Effective Date: March 2003
Reviewed: November 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Dynamic Motion X-ray (DMX), also known as cineradiography and videofluoroscopy of the spine has been investigated as an imaging tool to aid in diagnoses and assessment. It is promoted as a way to enable the treating physician to visualize the internal and external movements of the spinal column or biomechanics simultaneously. Videotaping of fluoroscopic images shows normal and abnormal joint motion, fractures, ligament damage and other anomalies. It has been investigated for use as an aid in the evaluation of musculoskeletal disorders and in a number of orthopedic, neurosurgical and chiropractic applications.
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Prior Approval:
Not applicable
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Policy:
DMX, cineradiography and videofluoroscopy of the spine are considered investigational.
The evidence at this time is insufficient to evaluate the effect on health outcomes of digital motion x-rays or cineradiography/videofluoroscopy of the spine for any indication.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 76120 Cineradiography/videoradiography, except where specifically included
- 76125 Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure)
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- Okawa A, Shinomiya K, Komori H, Muneta T, Arai Y, Nakai O. Dynamic motion study of the whole lumbar spine by videofluoroscopy. Spine 1998 Aug 15;23(16):1743-9.
- Takayanagi K, Takahashi K, Yamagata M, Moriya H, Kitahara H, Tamaki T.Using cineradiography for continuous dynamic-motion analysis of the lumbar spine. Spine 2001 Sep 1;26(17):1858-65.
- Zheng Y, Nixon MS, Allen R. Automated segmentation of lumbar vertebrae in digital videofluoroscopic images. IEEE Trans Med Imaging. 2004;23(1):45-52.
- ECRI. Videofluoroscopy of the Spine or Diagnosing Instability. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 April 16. 7p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- ECRI Institute. Videofluoroscopy of the spine for diagnosing instability. Plymouth Meeting (PA): ECRI Institute; 2010 April 13. 7 p. [ECRI hotline response]. Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
September 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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