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.
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.
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
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:
Evaluation of suspected defects as indicated by ANY ONE of the following:
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
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, the express terms of the health plan will govern.
There are no well-designed studies to support the use of diagnostic spinal ultrasound for the investigational uses listed on this policy.
American College of Radiology. (2016). ACR-AIUM-SPR-SRU practice parameter for the performance of an ultrasound examination of the neonatal and infant spine. Retrieved March 14, 2018 from http://www.acr.org.
American Institute of Ultrasound in Medicine (AIUM). (2014, April). Nonoperative spinal/paraspinal ultrasound in adults. Retrieved May 22, 2015 from http://www.aium.org.
American Institute of Ultrasound in Medicine (AIUM). (2016). AIUM practice guideline for the performance of an ultrasound examination of the neonatal and infant spine. Retrieved March 14, 2018 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: 4/12/2018