Medical Policy

This document addresses the use of dynamic spinal visualization, digital motion x-ray, cineradiography or videofluoroscopy, to produce moving images of the spine for the detection or evaluation of structural or functional abnormalities.

Investigational and Not Medically Necessary:

Dynamic spinal visualization, including, but not limited to, digital motion x-ray of the spine, with or without digitization of spinal x-rays and computerized analysis of the back or spine, is considered investigational and not medically necessary for all indications.

Dynamic spinal visualization, including, but not limited to, cineradiography, also known as videofluoroscopy, when used to visualize movement of the back or spine, is considered investigational and not medically necessary for all indications.

The current literature evaluating the clinical utility of dynamic spinal visualization techniques, including but not limited to digital motion x-ray and cineradiography (videofluoroscopy), for the evaluation and assessment of the spine is limited to a few studies involving very small numbers of participants. While these studies do indicate that there may be some benefit from the use of these technologies, further evidence from large controlled trials is needed to demonstrate that the results have significant impact on clinical care and are superior to currently available alternatives. At this time, the data is insufficient to support the use of dynamic spinal visualization, including digital motion x-rays, cineradiography, and videofluoroscopy of the spine for any indication.

Dynamic spinal visualization is a general term addressing the use of several different imaging technologies, including digital motion x-ray, cineradiography, and videofluoroscopy. These technologies allow the simultaneous visualization of movement of internal body structures, such as the skeleton, intervertebral discs and ligaments, with corresponding external body movement. All of these methods use x-rays to create images either digitally or on film, to allow visualization of internal structures while an individual is moving. These technologies have been proposed for the evaluation of back pain, orthopedic issues, and other conditions.

The American College of Radiology (ACR) Appropriateness Criteria^® Suspected Spine Trauma (2018) states that:

The literature has been uniformly negative in assessing the utility of static flexion-extension radiographs or dynamic fluoroscopy for detection of cervical spine ligamentous injuries. Studies have reported anywhere from 28% to 97% of flexion-extension studies are inadequate for evaluating ligament injury. Even when flexion-extension radiographs are technically adequate, they rarely demonstrate evidence of ligament instability, and positive studies rarely result in significant change in clinical management. The low rate of technically adequate studies along with the low sensitivity and specificity of flexion-extension radiographs makes this study undesirable for assessment of cervical spine ligament injuries. Furthermore, flexion-extension radiographs carry the real danger of producing neurologic injury. Flexion-extension radiographs fail to reveal most ligament injuries identified on MRI and can result in increased length of cervical immobilization.

Digital motion x-ray involves the use of either film x-ray or computer-based x-ray ‘snapshots’ taken in sequence as an individual moves in front of an x-ray camera. Film x-rays are digitized into a computer for manipulation while computer-based x-rays are automatically created in a digital format. The digitized snapshots are then put in order using a computer program and played on a video monitor, creating a moving image of the inside of the body. This moving image can then be evaluated by a physician alone or by using a computer that evaluates several aspects of the body’s structure to determine the presence or absence of abnormalitites.

Videofluoroscopy and cineradiography are different names for the same procedure that uses fluoroscopy to create real-time video images of internal body structures. Videofluroscopy works like a video camera, providing motion pictures of the inside of the body. The results of these techniques can be displayed on a video monitor as the procedure is being conducted. They can also be viewed or digitally analyzed at a later time.

Cineradiography (also known as Videofluoroscopy): A radiological procedure that uses fluoroscopy, an x-ray procedure, to make it possible to see structures in the body in real-time; this procedure has been proposed as a tool to diagnose or evaluate disease or injuries of the spine.

Digital motion x-ray: A technology in which successive x-rays are digitized and sequenced to create a video representation of movement of internal body structures.

Digitization: The process by which information is transformed from analog format into digital computer-based format.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the following procedure and diagnosis codes, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Harvey S, Hukins D, Smith F, et al. Measurement of lumbar spine intervertebral motion in the sagittal plane using videofluoroscopy. J Back Musculoskelet Rehabil. 2015; 29(3):445-457.
2. Hino H, Abumi K, Kanayama M, Kaneda K. Dynamic motion analysis of normal and unstable cervical spines using cineradiography. An in vivo study. Spine (Phila Pa 1976). 1999; 24(2):163-168.
3. Lindgren KA, Leino E, Manninen H. Cervical rotation lateral flexion test in brachialgia. Arch Phys Med Rehabil. 1992; 73(8):735-737.
4. Okawa A, Shinomiya K, Komori H, et al. Dynamic motion study of the whole lumbar spine by videofluoroscopy. Spine (Phila Pa 1976). 1998; 23(16):1743-1749.
5. Teyhen DS, Flynn TW, Childs JD, et al. Fluoroscopic video to identify aberrant lumbar motion. Spine. 2007; 32(7):E220-229.
6. Wong KW, Leong JC, Chan MK, et al. The flexion-extension profile of lumbar spine in 100 healthy volunteers. Spine (Phila Pa 1976). 2004; 29(15):1636-1641.

Government Agency, Medical Society and Other Authoritative Publications:

1. American College of Radiology (ACR) Appropriateness Criteria^® Suspected Spine Trauma. Revised in 2018. Available at: https://acsearch.acr.org/docs/69359/Narrative/. Accessed on March -11, 2024. 

1. National Institute of Neurological Disorders and Stroke. Back Pain. Available at: https://www.ninds.nih.gov/health-information/disorders/back-pain. Accessed on March 11, 2024.
2. National Library of Medicine. Health Topics: Back Pain. Available at: http://www.nlm.nih.gov/medlineplus/backpain.html. Accessed on March 11, 2024.

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