Nonoperative Diagnostic Spinal Ultrasound (Echography/Sonogram)
DESCRIPTION
Nonoperative diagnostic spinal ultrasound may be performed to diagnose congenital and acquired abnormalities in the neonatal and infant spine. Sonographic examination is accomplished by scanning through the normally incompletely ossified posterior elements. Results are comparable to magnetic resonance imaging (MRI) and because of the clinical ease of examination and lack of need for sedation, ultrasound is generally considered the first-line tool for diagnosis, with MRI reserved for cases in which ultrasound is inadequate or insufficient. In infants greater than six months in age, the examination can be limited, although the level of termination of the cord can often be identified.
POLICY
The use of nonoperative diagnostic spinal ultrasound is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
The use of nonoperative diagnostic spinal ultrasound, for the evaluation 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 or acquired anomalies for individuals over the age of two (2) 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
To evaluate individuals for congenital or acquired anomalies of the spine and spinal cord as indicated by ANY ONE of the following:
Lumbosacral stigmata known to be associated with spinal dysraphism (e.g., midline or paramedian masses, skin discolorations, skin tags, hair tufts, hemangiomas, small midline dimples, paramedian deep dimples)
The spectrum of caudal regression syndrome in infants with ANY ONE of the following:
Sacral agenesis
Anal atresia
Anal stenosis
Evaluation of suspected defects as indicated by ANY ONE of the following:
Cord tethering
Diastematomyelia
Hydromyelia
Syringomyelia
Detection of sequelae of injury as indicated by ANY ONE of the following:
Hematoma after spinal tap or birth injury
Sequelae of prior instrumentation, infection or hemorrhage
Posttraumatic leakage of cerebrospinal fluid (CSF)
Visualization of fluid with characteristics of blood products within the spinal canal in infants with intracranial hemorrhage
Guidance for lumbar puncture
Postoperative assessment for cord re-tethering
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
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 Institute of Ultrasound in Medicine (AIUM). (2019, November). Nonoperative spinal/paraspinal ultrasound in adults. Retrieved October 22, 2020 from http://www.aium.org.
American Institute of Ultrasound in Medicine (AIUM). (2021, October). Practice parameter for the performance of an ultrasound examination of the neonatal and infant spine. Retrieved October 17, 2022 from http://www.aium.org.
Centers for Medicare & Medicaid Services. CMS.gov. NCD for ultrasound diagnostic procedures (220.5). Retrieved May 22, 2015 from http://www.cms.gov.
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.
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: 2/8/2024