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Medical & Coding Policies
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Out-of-State & Non-Network
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DESCRIPTIONDynamic spinal visualization is a general term addressing different imaging technologies, including digital motion x-ray and videofluoroscopy (also known as cineradiography). These technologies allow the simultaneous visualization of movement of internal body structures, such as the spine (vertebrae), with corresponding external body movement. All of these methods use x-rays to create images either on film, on a video monitor, or on a computer screen. These technologies have been proposed for the evaluation of spinal disorders including low back pain.Digital motion x-ray involves the use of either film x-ray or computer-based x-ray ‘snapshots’ taken in sequence as a patient moves. Film x-rays are digitized into a computer for manipulation while computer-based x-rays are automatically created in a digital format. The digitized snapshots are then put in order using a computer program and played on a video monitor, creating a moving image of the inside of the body. This moving image can then be evaluated by a physician alone or by using a computer that evaluates several aspects of the body’s structure such as intervertebral flexion and extension to determine the presence or absence of abnormalities. Videofluoroscopy and cineradiography are different names for the same procedure that utilizes a technique called fluoroscopy to create real-time video images of internal structures of the body. Unlike standard x-rays that take a single picture at one point in time, fluoroscopy provides motion pictures of the body. The results of these techniques can be displayed on a video monitor as the procedure is being conducted as well as recorded to allow computer analysis or evaluation at a later time. Like digital motion x-ray, the results can be evaluated by a physician alone or using the assistance of computer analysis software.
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POLICYThe use of dynamic spinal visualization is considered investigational.
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POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
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POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
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POLICY HISTORY12/13/2006: Policy added.3/22/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC) 4/1/2008: Policy reviewed, no changes 04/09/2010: Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. 11/17/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes. 11/30/2012: Policy reviewed; no changes.
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SOURCE(S)Blue Cross Blue Shield Association Policy # 6.01.46
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CODE REFERENCEThis is not an all-inclusive list of non-covered procedure codes.All codes billed for this procedure are considered investigational and not eligible for coverage. Non-Covered Codes
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