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.
POLICY
The use of nonoperative diagnostic spinal ultrasound in the evaluation of newborns and infants is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
The use of nonoperative diagnostic spinal ultrasound, for the treatment of other conditions/diseases, including, but not limited to, the following is considered investigational:
To evaluate back pain or radicular symptoms (e.g., disc herniation, spinal stenosis, nerve root pathology)
For evaluation of congenital anomalies for individuals over the age of two years
MEDICAL APPROPRIATENESS
The use of nonoperative diagnostic spinal ultrasound is considered medically appropriate if ALL of the following criteria are met:
To evaluate newborns and infants two years of age or younger
Evaluate individuals for congenital anomalies of the spine and spinal cord (e.g., spina bifida, spinal dysraphism)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
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.
SOURCES
American Chiropractic Association. (2000). Current Policies. Retrieved May 27, 2010 from: http://www.acatoday.org/level2_css.cfm?T1ID=10&T2ID=117.
American Chiropractic College of Radiology. (2005). ACCR guideline for the use of diagnostic spinal ultrasound. Retrieved May 25, 2010 from: http://www.accr.org/ACCRspinalultrasound.pdf.
American Institute of Ultrasound in Medicine. (2009, April). Nonoperative spinal/paraspinal ultrasound in adults. Retrieved February 6, 2006 from: http://www.aium.org/publications/statements.aspx.
American Institute of Ultrasound in Medicine. (2007, October). AIUM practice guideline for the performance of an ultrasound examination of the neonatal spine. Retrieved May 25, 2010 from http://www.aium.org/publications/guidelines/neonatalSpine.pdf.
Bulas, D. (2010). Fetal evaluation of spine dysraphism. Pediatric Radiology, 40 (6), 1029-1037. (Level 5 Evidence)
Complete Guide to Medicare Coverage Issues. [Computer software]. (2011, November). Ultrasound diagnostic procedures (NCD 220.5, p. 2-176 & 2-177). Ingenix.
National Guideline Clearinghouse. (2008). ACR appropriateness criteria ® myelopathy. Retrieved May 27, 2010 from: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=13672&string=spinal+AND+ultrasound.
ORIGINAL EFFECTIVE DATE: 2/1/2001
MOST RECENT REVIEW DATE: 3/8/2012