GENERAL INFORMATION 

It is an expectation that all patients receive care/services from a licensed clinician.  All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided.  If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Purpose
Magnetic resonance imaging (MRI) produces high quality multiplanar images of organs and structures within the body without using ionizing radiation. It is used for evaluation, 
assessment of severity, and follow-up of diseases of the spine and is the preferred modality for imaging intervertebral disc degeneration. High contrast resolution (soft tissue contrast) and multiplanar imaging (sagittal as well as axial planes) are helpful in the evaluation of possible disc herniation and detecting nerve root compression. MRI is one of the most useful techniques to evaluate spine infection and is also used to evaluate tumors, cancer, and immune system suppression.

Policy
+If there is a combination request* for an overlapping body part, either requested at the same time or sequentially (within the past 3 months):

• The results of the prior study should be inconclusive or show a need for additional or follow-up imaging evaluation OR
• The office notes should clearly document an indication why overlapping imaging is needed and how it will change management for the patient (the entire spinal cord and/or autonomic postganglionic chain must be assessed).

(*Unless approvable in the combination section as noted in the guidelines)

INDICATIONS FOR THORACIC SPINE MRI
Evaluation of Neurologic Deficits (1,2)

• With any of the following new neurological deficits documented on physical exam
  • Extremity muscular weakness (and not likely caused by plexopathy or peripheral neuropathy)(3)
  • Pathologic (e.g., Babinski, Lhermitte's sign(4), Chaddock Sign(5), Hoffman’s and other upper motor neuron signs); OR abnormal deep tendon reflexes (and not likely caused by plexopathy, or peripheral neuropathy) 
  • Absent/decreased sensory changes along a particular thoracic dermatome (nerve distribution): pin prick, touch, vibration, proprioception, or temperature weakness (and not likely caused by plexopathy, or peripheral neuropathy)
  • Upper or lower extremity increase muscle tone/spasticity and likely localized to the thoracic spinal cord 
  • New onset bowel or bladder dysfunction (e.g., retention or incontinence)—not related to an inherent bowel or bladder process
  • Gait abnormalities, most likely cause by a suspected or known myelopathy (see Table 1 below for more details)
• Suspected thoracic cord compression with any neurological deficits as listed above

Evaluation of Back Pain (6,7)
With any of the following

• With new or worsening objective neurologic deficits (as listed above) on exam
• Failure of conservative treatment* for a minimum of six (6) weeks within the last six (6) months;

NOTE - Failure of conservative treatment is defined as one of the following:

• Lack of meaningful improvement after a full course of treatment; OR
• Progression or worsening of symptoms during treatment; OR
• Documentation of a medical reason the member is unable to participate in treatment

Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” treatment.

• With progression or worsening of symptoms during the course of conservative treatment*
• With an abnormal electromyography (EMG) or nerve conduction study (if performed) indicating a thoracic radiculopathy. (EMG is not recommended to determine the cause of axial lumbar, thoracic, or cervical spine pain)(8)
• Isolated back pain in pediatric population(9,10) (conservative care not required if red flags present). Red flags that prompt imaging include any ONE of the following:
  • Age 5 or younger
  • Constant pain
  • Pain lasting > 4 weeks
  • Abnormal neurologic examination
  • Early morning stiffness and/or gelling
  • Night pain that prevents or disrupts sleep
  • Radicular pain
  • Fever or weight loss or malaise
  • Postural changes (e.g., kyphosis or scoliosis)
  • Limp (or refusal to walk in a younger child)

Pre-Operative/Post-Operative/Procedural Evaluation
As part of initial pre-operative/post-operative/procedural evaluation (The best examinations are CT to assess for hardware complication, extent of fusion and pseudarthrosis and MRI for cord, nerve root compression, disc pathology, or post-op infection)(7,11)

• For preoperative evaluation/planning
• Prior to spinal cord stimulator to exclude canal stenosis if no prior MRI imaging of the thoracic spine has been done recently(12)
• CSF leak highly suspected and supported by patient history and/or physical exam findings (leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula or dural fistula))
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery in the last 6 months. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested (routine surveillance post-op not indicated without symptoms)
• Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
• New or changing neurological deficits or symptoms post-operatively(13)(see neurological deficit section above).
• When combo requests (see above statement+) are submitted (i.e., MRI and CT of the spine), the office notes should clearly document the need for both studies to be done simultaneously (e.g., the need for both soft tissue and bony anatomy is required)(14)
  • Combination requests where both thoracic spine CT and MRI thoracic spine are both approvable (not an all-inclusive list):
    • OPLL (Ossification of posterior longitudinal ligament)
      • Most common in cervical spine (rare but more severe in thoracic spine)(15)
      • Pathologic or complex fractures
      • Malignant process of spine with both bony and soft tissue involvement
      • Clearly documented indication for bony and soft tissue abnormality where assessment will change management for the patient

Evaluation of Suspected Myelopathy (16,17)

• Does NOT require conservative care
• Progressive symptoms including unsteadiness, broad-based gait, increased muscle tone, pins and needles sensation, weakness and wasting of the lower limbs, diminished sensation to light touch, temperature, proprioception, and vibration; limb hyperreflexia and pathologic reflexes; bowel and bladder dysfunction in more severe cases
• Any of the neurological deficits as noted above

Evaluation of Known or Suspected Multiple Sclerosis (16,18)

• Suspected or known multiple sclerosis (MS) with new or changing symptoms suggesting underlying thoracic spinal cord disease (i.e., transverse myelitis, progressive myelopathy)
• Suspected or known pediatric demyelinating diseases (MS/ADEM)

Combination Studies for Multiple Sclerosis 
Note: These body regions might be evaluated separately or in combination as guided by physical examination findings (e.g., localization to a particular segment of the spinal cord), patient history (e.g., symptom(s), time course, and where in the CNS the likely localization(s) is/are), and other available information, including prior imaging.

• Cervical and/or Thoracic MRI for evaluation of highly suspected multiple sclerosis (MS) when Brain MRI has indeterminate findings and/or does not fulfill the McDonald criteria for the diagnosis of MS
• Cervical and/or Thoracic MRI with suspected transverse myelitis —with appropriate clinical symptoms (e.g., bilateral weakness, sensory disturbance, and autonomic dysfunction which typically evolve over hours or days)
• Brain MRI with Cervical and/or Thoracic MRI for evaluation of neuromyelitis optica spectrum disorders (recurrent or bilateral optic neuritis; recurrent transverse myelitis)(19)
• Known MS- entire CNS axis (Brain, and/or Cervical and/or Thoracic spine) is approvable prior to the initiation or change of disease modification treatments and assess disease burden (to establish a new baseline)
• Known MS — Follow-up scans, including brain and spine imaging, if patients have known spine disease: 
  • 6-12 months after starting/changing treatment
  • Every 1-2 years while on disease-modifying therapy to assess for subclinical disease activity, less frequently when stable for 2-3 years

Evaluation of Trauma or Acute Injury (20)

• Presents with any of the following neurological deficits as above
• With progression or worsening of symptoms during the course of conservative treatment*
• History of underlying spinal abnormalities (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis) (Both MRI and CT are approvable)(21,22)
• When the patient is clinically unevaluable or there are preliminary imaging findings (x-ray or CT) needing further evaluation

MRI and CT provide complementary information. When indicated it is appropriate to perform both examinations

Evaluation of Known or New Compression Fractures (7,20)
(With Worsening Back Pain)

• With history of malignancy
  • To aid in differentiation of benign osteoporotic fractures from metastatic disease
    • A follow-up MRI in 6-8 weeks after initial MRI when initial imaging cannot decipher (indeterminate) benign osteoporotic fracture from metastatic disease(23)
• With an associated new focal neurologic deficit as above(20)
• Prior to a planned surgery/intervention or if the results of the MRI will change management

Evaluation of Tumor, Cancer, or Metastasis
With any of the Following
MRI is usually the preferred study but CT may be needed to further characterize solitary indeterminate lesions seen on MRI)(7,24,25)

• Primary tumor
  • Initial staging primary spinal tumor(26)
  • Follow-up of known primary cancer of patient undergoing active treatment within the past year or as per surveillance imaging guidance for that cancer
  • Known primary tumor with new signs or symptoms (e.g., new or increasing nontraumatic pain, physical, laboratory, and/or imaging findings)
  • With an associated new focal neurologic deficit as above(20)
• Metastatic tumor
  • With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
  • With an associated new focal neurologic deficit(20)
  • Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, radiculopathy or back pain that occurs at night and wakes the patient from sleep with known active cancer, physical, laboratory, and/or imaging findings) in a tumor that tends to metastasize to the spine(7,27,28)

Further Evaluation of Indeterminate Findings
Unless follow-up is otherwise specified within the guideline

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification. 
• One follow-up exam of a prior indeterminate MRI/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam).

Evaluation of Known or Suspected 
Infection/Abscess/Inflammatory disease (29,30)
When Thoracic Spine MRI is contraindicated or cannot be performed

• Infection
  • As evidenced by signs and/or symptoms, laboratory (i.e., abnormal white blood cell count, ESR and/or CRP) or prior imaging findings
  • Follow-up imaging of infection
    • With worsening symptoms/laboratory values (i.e., white blood cell count, ESR/CRP) or radiographic findings
• Spondyloarthropathies
  • Ankylosing Spondylitis/Spondyloarthropathies with non-diagnostic or indeterminate x-ray and appropriate rheumatology workup

E.g., Osteomyelitis

Evaluation of Spine Abnormalities Related to Immune System Suppression (29)

• As evidenced by signs/symptoms, laboratory, or prior imaging findings

E.g., HIV, chemotherapy, leukemia, or lymphoma

Other Indications for a Thoracic Spine MRI
Note: See combination requests, below, for initial advanced imaging assessment and pre-operatively

• Tethered cord or spinal dysraphism (known or suspected), based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata(31,32,33)
• Known Arnold-Chiari syndrome (For initial imaging (one-time initial modality assessment) see combination below)
  • Known Chiari I malformation without syrinx or hydrocephalus, follow-up imaging after initial diagnosis with new or changing signs/symptoms or exam findings consistent with spinal cord pathology(34)
  • Known Chiari II (Arnold-Chiari syndrome), III, or IV malformation
• Syrinx or syringomyelia (known or suspected)
  • With neurologic findings and/or predisposing conditions (e.g., Chiari malformation, prior trauma, neoplasm, arachnoiditis, severe spondylosis)(35)
  • To further characterize a suspicious abnormality seen on prior imaging
  • Known syrinx with new/worsening symptoms
• Toe walking in a child with signs/symptoms of myelopathy localized to the Thoracic Spine(36)
• Suspected neuroinflammatory Conditions/Diseases (e.g., sarcoidosis, Behcet’s)-After detailed neurological exam and appropriate initial work up completed
• Follow-up known neuroinflammatory Conditions/Diseases (e.g., sarcoidosis, Behcet’s) with new or worsening signs/symptoms or to evaluate treatment response

Genetic Syndromes and Rare Diseases

• Von Hippel Lindau (VHL) at least every other year starting at age 16(37)
• For other syndromes and rare diseases not otherwise addressed in the guideline, coverage is based on a case-by-case basis using societal guidance.

Combination Studies
Brain/Cervical/Thoracic/Lumbar/Abdomen MRI

• Von Hippel Lindau (VHL) every 2 years starting at age 15

Brain MRI/Cervical Spine MRI/Thoracic Spine MRI

• Combination studies for MS: These body regions might be evaluated separately or in combination as guided by physical examination findings (e.g., localization to a particular segment of the spinal cord), patient history (e.g., symptom(s), time course, and where in the CNS the likely localization(s) is/are), and other available information, including prior imaging.
  • For evaluation of neuromyelitis optica spectrum disorders (recurrent or bilateral optic neuritis; recurrent transverse myelitis) (38)
  • For known MS, prior to the initiation or change of disease modification treatments and assess disease burden (to establish a new baseline) (39,40)
  • Follow-up scans, including brain and spine imaging, if patients have known spine disease:
    • 6-12 months after starting/changing treatment
    • Every 1-2 years while on disease-modifying therapy to assess for subclinical disease activity, less frequently when stable for 2-3 years

Brain MRI/Cervical Spine MRI/ Thoracic Spine MRI/Lumbar Spine MRI (any Combination)

• For initial evaluation of a suspected Arnold Chiari malformation
• Follow-up imaging of a known type II or type III Arnold Chiari malformation. For Arnold Chiari type I, follow-up imaging only if new or changing signs/symptoms (41,42,43)
• Oncological Applications (e.g., primary nervous system, metastatic)
  • Drop metastasis from brain or spine
  • Suspected leptomeningeal carcinomatosis(44)
• CSF leak highly suspected and supported by patient history and/or physical exam findings (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula)
• For evaluation of known Arnold-Chiari Malformation
• Tumor evaluation and monitoring in cancer predisposition syndrome
  • Von Hippel Lindau (VHL) - imaging of the brain and spinal cord for hemangioblastomas every 2 years starting at age 14 (45,46,47)
  • Rhabdoid Tumor Predisposition Syndrome- Brain and Spine MRI at diagnosis and monthly age 0-6 months if whole body MRI not done; Q2-3 months age 7-18months, Q3months age 19 months-5 years
  • NF-2- Brain IAC annually starting at the age of 10 years and spinal imaging at baseline and every 2 to 3 years with more frequent imaging, if warranted, based on sites of tumor involvement (48)
  • Schwannomatosis - Brain and spine MRI every two to three years beginning at age 12 years

Note: diagnosis is met with both genetic testing AND clinical features due to incomplete penetrance

Cervical and Thoracic MRI

• Initial evaluation of known or suspected syrinx or syringomyelia
  • With neurologic findings and/or predisposing conditions (e.g., Chiari malformation, prior trauma, neoplasm, arachnoiditis, severe spondylosis(35)
  • To further characterize a suspicious abnormality seen on prior imaging
  • Known syrinx with new/worsening symptom

Cervical and/or Thoracic and/or Lumbar MRIs (any Combination)
Note: These body regions might be evaluated separately or in combination as documented in the clinical notes by physical examination findings (e.g., localization to a particular segment of the spinal cord), patient history, and other available information, including prior imaging.

Exception- Indications for combination studies(49,50): Are approved indications as noted below and being performed in children who will need anesthesia for the procedure

• Any combination of these studies for:
  • Survey/complete initial assessment of infant/child with congenital scoliosis or juvenile idiopathic scoliosis under the age of 10(51,52,53) (e.g., congenital scoliosis, idiopathic scoliosis, scoliosis with vertebral anomalies)
  • In the presence of neurological deficit, progressive spinal deformity, or for preoperative planning(54)
  • Back pain with known vertebral anomalies (hemivertebrae, hypoplasia, agenesis, butterfly, segmentation defect, bars, or congenital wedging) in a child on preliminary imaging
  • Scoliosis with any of the following(55):
    • Progressive spinal deformity
    • Neurologic deficit (new or unexplained)
    • Early onset
    • Atypical curve (e.g., short segment, >30◦ kyphosis, left thoracic curve, associated organ anomalies)
    • Pre-operative planning; OR
    • When office notes clearly document how imaging will change management
• Arnold-Chiari malformations(33,56)
  • Arnold-Chiari I
    • For evaluation of spinal abnormalities associated with initial diagnosis of Arnold-Chiari Malformation. (C/T/L spine due to association with tethered cord and syringomyelia), and initial imaging has not been completed(51)
  • Arnold-Chiari II-IV - For initial evaluation and follow-up as appropriate
    • Usually associated with open and closed spinal dysraphism, particularly meningomyelocele(31)
• Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata,(31,32,33) when anesthesia required for imaging(57) (e.g., meningomyelocele, lipomeningomyelocele, diastematomyelia, fatty/thickened filum terminale, and other spinal cord malformations)
• Oncological Applications (e.g., primary nervous system, metastatic)
  • Drop metastasis from brain or spine (imaging also includes brain)
  • Suspected leptomeningeal carcinomatosis (LC)(58)
  • Any combination of these for spinal survey in patient with metastases
  • Tumor evaluation and monitoring in neurocutaneous syndromes
• CSF leak highly suspected and supported by patient history and/or physical exam findings (leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula))(59)

Combination Studies for Malignancy for Initial Staging or Restaging
Unless otherwise specified in this guideline, indication for combination studies for malignancy for initial staging or restaging:

• Concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Abdomen, Brain, Chest, Neck, Pelvis, Cervical Spine, Thoracic Spine or Lumbar Spine.

Rationale

*Conservative Treatment
Non-operative conservative treatment should include a multimodality approach consisting of at least one (1) active and one (1) inactive component targeting the affected region.

Active Modalities

• Physical therapy
• Physician-supervised home exercise program**
• Chiropractic care

Inactive Modalities

• Medications (e.g., NSAIDs, steroids, analgesics)
• Injections (e.g., epidural injection, selective nerve root block)
• Medical Devices (e.g., TENS unit, bracing)

**Home Exercise Program
The following two elements are required to meet conservative therapy guidelines for HEP: (11)

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor; AND
• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (e.g., increased pain or inability to physically perform exercises).

Gait and spine imaging
Table 1(60)

Gait                          Characteristic                                     Work up/Imaging
Hemiparetic	Spastic unilateral, circumduction	Brain and/or, cervical spine imaging based on associated symptoms
Diplegic	Spastic bilateral, circumduction	Brain, cervical and thoracic spine imaging
Myelopathic	Wide based, stiff, unsteady	Cervical and/or thoracic spine MRI based on associated symptoms
Cerebellar Ataxic	Broad based, clumsy, staggering, lack of coordination, usually also with limb ataxia	Brain imaging — see Brain MRI Guideline
Apraxic	Magnetic, shuffling, difficulty initiating	Brain imaging — see Brain MRI Guideline
Parkinsonian	Stooped, small steps, rigid, turning en bloc, decreased arm swing	Brain imaging — see Brain MRI Guideline
Choreiform	Irregular, jerky, involuntary movements	Medication review, consider brain imaging as per movement disorder brain MR guidelines
Sensory ataxic	Cautious, stomping, worsening without visual input (ie + Romberg)	EMG, blood work, consider spinal (cervical or thoracic cord imaging) imaging based on EMG
Neurogenic	Steppage, dragging of toes	EMG initial testing; BUT if there is a foot drop, lumbar spine MRI is appropriate without EMG Pelvis MR if there is evidence ofplexopathy
Vestibular	Insecure, veer to one side, worse when eyes closed, vertigo	Consider brain/IAC MRI — see Brain MRI Guideline

Myelopathy 
Symptom severity varies, and a high index of suspicion is essential for making the proper diagnosis in early cases. Symptoms of pain and radiculopathy may not be present. The natural history of myelopathy is characterized by neurological deterioration. The most frequently encountered symptom is gait abnormality (86%), followed by increased muscular reflexes (79.1%), pathological reflexes (65.1%), paresthesia of upper limb (69.8%), and pain (67.4%)(17)

MRI and Neurocutaneous Syndromes 

• In NF-1, clinical evaluation appears to be more useful to detect complications than is screening imaging in asymptomatic patients. Imaging is indicated in evaluation of suspected tumors based on clinical evaluation and for follow-up of known intracranial and intraspinal tumors.(61)
• Conversely in NF-2, routine MR imaging screening is always indicated, given the high prevalence of CNS tumors, especially vestibular schwannomas. In patients with NF-2, routine screening brain/IAC imaging is indicated annually starting from age 10, if asymptomatic, or earlier with clinical signs/symptoms. Most individuals with NF2 eventually develop a spinal tumor, mostly commonly schwannomas, but meningioma and ependymomas are also seen. Spinal imaging at baseline and every 2 to 3 years is also advised with more frequent imaging, if warranted, based on sites of tumor involvement.(62)
• In patients with Tuberous Sclerosis, Brain MRI should be obtained every 1-3 years up until age 25 for surveillance for CNS abnormalities.(63)
• In Von Hippel Lindau Syndrome, imaging of the brain and spinal cord for hemangioblastomas is recommended every 2 years.(64)

Contraindications and Preferred Studies

• Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester)
• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non-compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machin

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Coding Section

Codes	Number	Description
CPT	72146	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material
	72147	with contrast material(s)
	72157	thoracic
	0698T	Quantitative magnetic resonance for analysis of tissue composition (e.g., fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, multiple organs

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward 

12/02/2024	Annual review, reformatting policy for clarity and consistency, also adding contraindications and preferred studies, updating combination studies, adding genetic and rare disease section, updating rationale and references.
01/01/2024	New Policy