This policy version was replaced May 30, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Dynamic spinal visualization is a general term addressing several imaging technologies including digital motion x-ray, dynamic magnetic resonance imaging (MRI) and videofluoroscopy. These allow the simultaneous visualization of movement of internal body structures, such as the spine (vertebrae), with corresponding external body movement. Results of this technique can be displayed on a video monitor as a procedure is being conducted; results can also be recorded to allow computer analysis or evaluation at a later time.
Vertebral motion analysis systems provide assisted bending with fluoroscopic imaging and computerized analysis. The device uses facial recognition software to track vertebral bodies across the images. In 2012, the KineGraph VMA™ (Vertebral Motion Analyzer) was cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process. The system includes a Motion Normalizer™ for patient positioning, standard fluoroscopic imaging, and automated image recognition software.
I. Dynamic spinal visualization by any method is considered EXPERIMENTAL/INVESTIGATIVE for all indications due to the lack of clinical evidence demonstrating an impact on improved health outcomes.
II. Vertebral motion analysis by any method is considered EXPERIMENTAL/INVESTIGATIVE for all indications due to the lack of clinical evidence demonstrating an impact on improved health outcomes.
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
