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.