Post#10 MRI Lumbar Spine: Six "Back FAQs" to help you Avoid Peer-to-Peer Calls 

Q-1:  Do Prior Authorization companies require a plain spine X-ray before approving an MRI Lumbar spine?

A-1:  X-ray of the spine is not a prerequisite for most patients with muscular or discogenic back  pain. However, there are a few exceptions and these patients do require an x-ray:
•    Spinal trauma or suspected fracture
•    Suspected compression fracture
•    Ankylosing Spondylitis
•    Lumbar Spondylolysis or Spondylolithesis
•    Sacroiliac joint conditions
•    Scoliosis or Kyphosis and other spinal deformities
•    Post-operative Spinal pain

Q-2:  When is a spine CT preferred over a spine MRI?

A-2:  CT spine is preferred for patients: 
•    who cannot have an MRI due to metal or implanted devices that are MRI-incompatible
•    with suspected spinal neoplastic disease (primary or metastatic) if a CT myelogram or CTdiscogram would be needed by the specialist. 
•    with spinal trauma and suspected or known fracture especially if spinal instability or spinal nerve compression is present. 
•    with spondylolysis when the x-ray is negative and MRI is equivocal, indeterminate, or non-diagnostic.     
•    to assess spinal fusion (where x-rays are insufficient) when pseudoarthrosis is suspected. CT is not a routine post op assessment. 
•    with congenital or acquired spinal deformity for pre-op evaluation to define abnormal spinal anatomy that may determine the potential surgical procedure.     

Q-3:  In patients with chronic back pain (who have had previous lumbar MRIs) what is the role of repeated MRI scanning? 

A-3: Additional imaging has not been shown to be of value for stable, longstanding back pain in the absence of neurological abnormalities or changes in symptoms or physical exam findings. 

Q-4: What is the role of advanced imaging for compression fractures? 

A-4:  Guidelines support either MRI without contrast or CT without contrast for compression fracture if the following criteria are met: 
•    A plain film of the affected spine segment is required as initial imaging
•    a new spinal compression fracture is seen on x-ray
•    suspected compression with non-diagnostic x-rays but pain greater than 1 week in a patient predisposed to insufficiency fractures.
•    a known insufficiency spinal compression in patients who are candidates for kyphoplasty, vertebroplasty or other surgical procedure. 
•    OR When a red flag is present 

Q-5:  What is the role of advanced imaging for suspected or known spinal stenosis? 

A-5:  Guidelines support either MRI without contrast or CT without contrast for suspected or known spinal stenosis in the presence of: 
•    a red flag sign or
•    failure to improve after a 6 week trial of physician-directed treatment and clinical re-evaluation or
•    severe symptoms of neurogenic claudication restricting normal activity requiring the frequent use of narcotic analgesics.             

Q-6: What are the guidelines for imaging for sacroiliac joint conditions and coccydynia? 

A-6:  MRI pelvis without contrast (72195) (OR CT pelvis without contrast (72192) if MRI is contraindicated) is indicated after a
•    Face-to-face office visit and examination within the last 60 days and
•    Plain x-ray of the sacrum and coccyx are negative for fracture and
•    Failure of a 6 week trial of conservative treatment or observation and
•    Follow up re-evaluation with a face-to-face visit OR phone call, OR email, or other communication.