Cineradiography of the Spine or Dynamic Motion X-Ray  Printer-Friendly Version
Medical Policy: 06.01.02
Original Effective Date: March 2003
Reviewed: November 2007
Revised:
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
Policy:
DMX, cineradiography and videofluoroscopy of the spine are considered investigational.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT code 76120 Cineradiography/videoradiography, except where specifically included
- CPT code 76125 Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure)
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Selected References:
- 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave.
Des Moines, IA 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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