![]() ![]() Injection, gadobenate dimeglumine (MultiHance multipack), per ml Injection, gadobenate dimeglumine (MultiHance), per ml Injection, gadoteridol, (ProHance multipack), per ml HCPCS codes covered if selection criteria are met: Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences cervical Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar without contrast material Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic without contrast material Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical without contrast material Without contrast material, followed by contrast material(s) and further sectionsĬomputed tomography, thoracic spine without contrast materialĬomputed tomography, lumbar spine without contrast material Codes requiring a 7th character are represented by "+":ĬPT codes covered if selection criteria are met:Ĭomputed tomography, cervical spine without contrast material Information in the below has been added for clarification purposes. Table: CPT Codes / HCPCS Codes / ICD-10 Codes Code CPB 0202 - Magnetic Resonance Spectroscopy (MRS).CPB 0093 - Open Air, Low Field Strength, and Positional Magnetic Resonance Imaging (MRI).Aetna considers dual-energy CT experimental and investigational for the evaluation of bone marrow edema and fracture lines in acute vertebral fractures because the clinical value of this approach has not been established.Aetna considers the use of routine MRI after a normal CT of the cervical spine in obtunded or comatose individuals experimental and investigational because the clinical value of this approach has not been established. ![]() Aetna considers dynamic-kinetic MRI experimental and investigational for evaluation of the cervical spine because its effectiveness has not been established.Aetna considers the use of MRI for further evaluation of unstable injury in neurologically intact individuals with blunt trauma after a negative cervical spine CT result not medically necessary.Clinical guidelines, including those from the Agency for Healthcare Policy and Research, have consistently recommended against routine imaging studies for acute low back pain. Aetna considers MRI and CT of the spine experimental and investigational for all other indications because their clinical value for indications other than the ones listed above has not been established.Suspected spinal fracture and/or dislocation secondary to trauma (if plain films are not conclusive) orįootnotes for conservative therapy * Conservative therapy = moderate activity, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants.Suspected spinal cord injury secondary to trauma or.Suspected infectious process (e.g., osteomyelitis epidural abscess of the spine or soft tissue) or.Spondylolisthesis and degenerative disease of the spine that has not responded to 4 weeks of conservative therapy Footnotes for conservative therapy* or. ![]()
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