It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy
INDICATIONS FOR THORACIC SPINE CT
+If there is a combination request* for an overlapping body part, either requested at the same time or sequentially (within the past 3 months):

• The results of the prior study should be inconclusive or show a need for additional or follow-up imaging evaluation OR
• The office notes should clearly document an indication why overlapping imaging is needed and how it will change management for the patient (the entire spinal cord and/or autonomic postganglionic chain must be assessed).

 (*Unless approvable in the combination section as noted in the guidelines)

Evaluation of Neurologic Deficits^1,2
When thoracic spine MRI is contraindicated or inappropriate

• With any of the following new neurological deficits documented on physical exam
  • Extremity muscular weakness (and not likely caused by plexopathy or peripheral neuropathy)³
  • Pathologic (e.g., Babinski, Lhermitte's sign,⁴ Chaddock Sign,⁵ Hoffman’s and other upper motor neuron signs); OR abnormal deep tendon reflexes (and not likely caused by plexopathy, or peripheral neuropathy)
  • Absent/decreased sensory changes along a particular thoracic dermatome (nerve distribution): pin prick, touch, vibration, proprioception, or temperature weakness (and not likely caused by plexopathy, or peripheral neuropathy)
  • Upper or lower extremity increase muscle tone/spasticity and likely localized to the thoracic spinal cord
  • New onset bowel or bladder dysfunction (e.g., retention or incontinence) — not related to an inherent bowel or bladder process
  • Gait abnormalities (see Table1 below for more details)
• Suspected cord compression with any neurological deficits as listed above

Evaluation of Back Pain⁶
With any of the following when thoracic spine MRI is contraindicated

• With an abnormal electromyography (EMG) or nerve conduction study (if performed) indicating a thoracic radiculopathy. (EMG is not recommended to determine the cause of axial lumbar, thoracic, or cervical spine pain.)⁷
• Isolated back pain in pediatric population^(8,9) (conservative care not required if red flags present). Red flags that prompt imaging include any ONE of the following:
  • Age 5 or younger
  • Constant pain
  • Pain lasting > 4 weeks
  • Abnormal neurologic examination
  • Early morning stiffness and/or gelling
  • Night pain that prevents or disrupts sleep
  • Radicular pain
  • Fever or weight loss or malaise
  • Postural changes (e.g., kyphosis or scoliosis)
  • Limp (or refusal to walk in a younger child)

Pre-Operative/Post-Operative/Procedural Evaluation
As part of initial pre-operative/post-operative/procedural evaluation (The best examinations are CT to assess for hardware complication, extent of fusion and pseudarthrosis and MRI for cord, nerve root compression, disc pathology, or post-op infection.)⁶
Note: If ordered by neurosurgeon or orthopedic surgeon for purposes of surgical planning, a contraindication to MRI is not required.

• Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
• New or changing neurological deficits or symptoms post-operatively¹¹ (see

neurological deficit section above.)

• When combo requests are submitted (i.e., MRI and CT of the spine), the office notes should clearly document the need for both studies to be done simultaneously (e.g., the need for both soft tissue and bony anatomy is required)¹²
  • Combination requests where both thoracic spine CT and MRI thoracic spine are both approvable (not an all-inclusive list):
    • OPLL (Ossification of posterior longitudinal ligament)

□     Most common in cervical spine (rare but more severe in thoracic spine)¹³

• Pathologic or complex fractures
• Malignant process of spine with both bony and soft tissue involvement
• Clearly documented indication for bony and soft tissue abnormality where assessment will change management for the patient

Evaluation of Suspected Myelopathy^14,15
When thoracic spine MRI is contraindicated

• Does NOT require conservative care
• Progressive symptoms including unsteadiness; broad-based gait; increased muscle tone; pins and needles sensation; weakness and wasting of the lower limbs; diminished sensation to light touch, temperature, proprioception, and vibration; limb hyperreflexia and pathologic reflexes; bowel and bladder dysfunction in more severe cases
• Any of the neurological deficits as noted above

Evaluation of Trauma or Acute Injury¹⁶

• Presents with any of the following neurological deficits as above
• With progression or worsening of symptoms during the course of conservative treatment*
• History of underlying spinal abnormalities (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis) (Both MRI and CT are approvable)^17,18,19
• When the patient is clinically unevaluable or there are preliminary imaging findings (x-ray or CT) needing further evaluation

MRI and CT provide complementary information. When indicated it is appropriate to perform both examinations

Evaluation of Known Fracture or Known/New Compression Fractures^16,20
(With Worsening Back Pain)

• To assess union of a fracture when physical examination, plain radiographs, or prior imaging suggest delayed or non-healing
• To determine the position of fracture fragments
• With history of malignancy (if MRI is contraindicated or cannot be performed)
• With an associated new focal neurologic deficit as above
• Prior to a planned surgery/intervention or if the results of the CT will change management

CT Myelogram^10,21
When MRI cannot be Performed/Contraindicated/Surgeon Preference

When signs and symptoms inconsistent or not explained by the MRI findings

• Demonstration of the site of a CSF leak (known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula)
• Surgical planning, especially regarding to the nerve roots or evaluation of dural sac

Evaluation of Tumor, Cancer, or Metastasis
With any of the following:

MRI is usually the preferred study (CT may be needed to further characterize solitary indeterminate lesions seen on MRI)^22,23

• Primary tumor
  • Initial staging primary spinal tumor²⁴
  • Follow-up of known primary cancer of patient undergoing active treatment within the past year or as per surveillance imaging guidance for that cancer
  • Known spinal tumor with new signs or symptoms (e.g., new or increasing nontraumatic pain, physical, laboratory, and/or imaging findings)
  • With an associated new focal neurologic deficit as above¹⁶
• Metastatic tumor
  • With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
  • With an associated new focal neurologic deficit¹⁶
  • Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, radiculopathy or neck pain that occurs at night and wakes the patient from sleep with known active cancer, physical, laboratory, and/or imaging findings) in a tumor that tends to metastasize to the spine^25,26

Evaluation of Known or Suspected Infection/Abscess/Inflammatory Disease²⁷
When thoracic spine MRI is contraindicated or cannot be performed

• As evidenced by signs and/or symptoms, laboratory (i.e., abnormal white blood cell count, ESR and/or CRP) or prior imaging findings
• Follow-up imaging of infection
  • With worsening symptoms/laboratory values (i.e., white blood cell count, ESR/CRP) or radiographic findings