Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2006 Title: Chiropractic X-Rays
Revision Date: 01/01/2017 Document: BI220:00
CPT Code(s): 72010-72120
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

QualChoice covers many spine X-rays taken by chiropractors in their offices.


Medical Statement

1)    CPT codes 72081 – 72084 – Total Spine Exam are not covered for chiropractic treatment.

2)    CPT codes 72081 – 72084 and 72120 – Scoliosis Exams are covered only if performed at an imaging center or hospital and read by a radiologist.

3)    CPT codes 72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080, 72100, 72110, 72114 – Regional Skeletal X-rays are considered medically necessary for:

a)    Any age, with any of the following:

i)            A known congenital anomaly of the spine and no study available within the prior 12 months.

ii)          A history of a malignancy, with unexplained new symptoms (please coordinate all radiology with the PCP and/or Oncologist).

iii)         A history of spondylolisthesis with no study within 18 months and/or new trauma.

iv)        Significant trauma (head injury, spine injury) including spinal antalgia with ambulation severely impaired (e.g.: torticollis, LBS acute IVD displacement with antalgia and visually distorted posture).

v)          Unexplained weight loss with orthopedic chief complaints.

vi)        Known osteoporosis. If the patient is at risk but undiagnosed, a referral to the patient’s primary care physician for assessment or bone density study may be indicated. Skeletal X-ray is not acceptable as a screening tool for osteoporosis.

vii)       A palpable abnormal mass

viii)      Substance abuse

ix)        Prolonged corticosteroid use

x)          Fever of unknown origin – If the patient is febrile without known cause, the patient should be referred to the PCP for evaluation before having any manipulative treatment considered.

xi)        Suspected physical abuse

xii)       Suspicion of an extremity or spinal fracture

xiii)      No response to treatment after two weeks of conservative care.

b)    Age over 50, with no X-rays within the past year and with any of:

i)            Radiating pain

ii)          Extremity numbness

iii)         Extremity motor weakness or asymmetrical deep tendon reflexes

c)     Age over 60 with symptoms and no X-rays within the past 18 months.

4)    Please remember that ionizing radiation has a cumulative effect on the human body.

a)    Chiropractors are required to keep a record of their patients’ exposure to all X-ray studies, including CT, dental X-ray and radiation therapy.

b)    For the safety of the patient, coordinate care with other providers and do not duplicate studies or perform unnecessary X-rays.

5)    For children aged 16 years and younger, X-rays are covered only if performed at an imaging center or hospital and read by a radiologist.

 

Codes Used In This BI:

 

72010

X-ray exam of entire spine (code deleted 1/1/16)

72020

X-ray exam of spine-single view

72040

X-ray exam of spine-cervical/2 or 3 views

72050

X-ray exam of spine-cervical/4 or 5 views

72052

X-ray exam of spine-cervical/6 or more views

72069

X-ray exam of spine-thoracolumbar, standing (scoliosis) (code deleted 1/1/16)

72070

X-ray exam of spine-thoracic/2 views

72072

X-ray exam of spine-thoracic/3 views

72074

X-ray exam of spine-thoracic/min of 4 views

72080

72081

 

72082

72083

72084

X-ray exam of spine-thoracolumbar/2 views

X-ray exam, spine, entire thoracic & lumbar, incl skull, cervical and sacral spine if performed (scoliosis eval); 1 view (new code 1/1/16)

2 or 3 views (new code 1/1/16)

4 or 5 views (new code 1/1/16)

Min of 6 views (new code 1/1/16)

72090

X-ray exam of spine-scoliosis study incl supine & erect studies (code deleted 1/1/16)

72100

X-ray exam of spine-lumbosacral/2 or 3 views

72110

X-ray exam of spine-min of 4 views

72114

X-ray exam of spine-complete including bending views/min of 6 views

72120

X-ray exam of spine-bending views only/2 or 3 views


Background

1)    We recommend that the standard views for a minimum series of diagnostic imaging of an area should be 2 right angle views (LBS, THS), or APOM, AP and Lat csp (3 views).

2)    X-Ray studies that are not of diagnostic quality should be retaken and not billed as additional views.

3)    X-Ray equipment must follow all guidelines promulgated by the Arkansas Department of Health. Failure to pass Health Department inspection must be reported to QCA immediately.


Reference
www.oregon.gov/OBCE/publications/FINAL_DX_IMAGING.pdf.

Addendum:

Effective 01/01/17:  CPT code updates incorporated into policy.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.