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.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

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 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:   http://www.neurology.org/content/51/2/343.full.html##ref-list-1.

American Chiropractic Association. (2011). Current Policies. Diagnostic ultrasound of the adult spine. Retrieved September 30, 2013 from: http://www.acatoday.org/level2_css.cfm?T1ID=10&T2ID=117.

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.

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 http://www.guidelines.gov.

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:  http://www.cms.gov/medicare-coverage-database.

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.

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.

ORIGINAL EFFECTIVE DATE:  2/1/2001   

MOST RECENT REVIEW DATE:  6/11/2015

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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