BlueCross BlueShield of Tennessee Medical Policy Manual

Nonoperative Diagnostic Spinal Ultrasound (Echography/Sonogram)


Ultrasonography is a noninvasive imaging technique that uses high-frequency sound waves. A conducting gel is applied to the skin overlying the area to be examined. The individual then lies on an examination table or bed while the physician or technician passes a transducer over the area. The reflected sound waves are converted into images that are viewed on a monitor.





The current literature is very limited. No well-designed studies are found in peer-reviewed published literature to support the use of diagnostic spinal ultrasound for the investigational uses listed on this policy.


American Academy of Neurology’s Therapeutics and Technology Assessment Subcommittee. (1998) Review of the literature on spinal ultrasound for the evaluation of back pain and radicular disorders. Retrieved May 22, 2015 from:

American Chiropractic Association. (2011). Current Policies. Diagnostic ultrasound of the adult spine. Retrieved September 30, 2013 from:

American Institute of Ultrasound in Medicine (AIUM). (2011, April). AIUM practice guideline for the performance of an ultrasound examination of the neonatal spine. Retrieved September 30, 2013 from

American Institute of Ultrasound in Medicine (AIUM). (2014, April). Nonoperative spinal/paraspinal ultrasound in adults. Retrieved May 22, 2015 from

Bulas, D. (2010). Fetal evaluation of spine dysraphism. Pediatric Radiology, 40 (6), 1029-1037.

National Guideline Clearinghouse. (2011). ACR appropriateness criteria® myelopathy. Retrieved September 30, 2013 from

U. S. Department of Health and Human Services. Center for Medicare and Medicaid Services. (2007). (NCD) for Ultrasound diagnostic procedures (220.5). Retrieved May 22, 2015 from:

U. S. Food and Drug Administration. (2012, February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K112953. Retrieved September 30, 2013 from

Varras, M., & Akrivis, C. (2010). Prenatal diagnosis for fetal hemivertebra at 20 weeks’ gestation with literature review. International Journal of General Medicine, 3, 197-201.




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