BlueCross BlueShield of Tennessee Medical Policy Manual

Nonoperative Diagnostic Spinal Ultrasound (Echography/Sonogram)

DESCRIPTION

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.

Sonographic examination of the pediatric spinal canal is most successful in the newborn period and early infancy and is accomplished by scanning through the normally incompletely ossified posterior elements.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

There are no well-designed studies to support the use of diagnostic spinal ultrasound for the investigational uses listed on this policy.

SOURCES

American College of Radiology. (2014). ACR-AIUM-SPR-SRU practice parameter for the performance of an ultrasound examination of the neonatal spine. Retrieved May 23, 2016 from http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Neonatal_Spine.pdf.

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 http://www.aium.org/resources/guidelines/neonatalSpine.pdf.

American Institute of Ultrasound in Medicine (AIUM). (2014, April). Nonoperative spinal/paraspinal ultrasound in adults. Retrieved May 22, 2015 from http://www.aium.org/officialStatements/18.

Centers for Medicare & Medicaid Services. CMS.gov. NCD for ultrasound diagnostic procedures (220.5). Retrieved May 22, 2015 from:  http://www.cms.gov/medicare-coverage-database.

Heidari, P., Farahbakhsh, F., Rostami, M., Noormohammadpour, P., & Kordi, R. (2015). The role of ultrasound in diagnosis of the causes of low back pain: a review of the literature. Asian Journal of Sports Medicine, 6 (1), e23803.  (Level 1 evidence)

Oulego-Erroz, I., Mora-Matilla, M., Alonso_Quintela, P., Rodriguez-Blanco, S., Mata-Zubillaga, D., & Lὀpez de Armentia, S. (2014). Ultrasound evaluation of lumbar spine anatomy in newborn infants: implications for optimal performance of lumbar puncture. The Journal of Pediatrics, 165, 862-865. (Level 4 evidence)

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 http://www.accessdata.fda.gov/cdrh_docs/pdf11/k112953.pdf.

van den Hendel, D., Sloots, C., de Jong, T., Lequin, M., & Wijnen, R. (2016). Screening and treatment of tethered spinal cord in anorectal malformation patients. European Journal of Pediatric Surgery, 26 (1), 22-28. Abstract retrieved May 23, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  2/1/2001   

MOST RECENT REVIEW DATE:  10/8/2016

ID_BT

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