72156_policy_evolent.pdf
EVOLENT · CPT 72156
completed
336fc421
Extraction complete!
Pathways
✓
Evaluation of new neurologic deficits including extremity weakness, abnormal reflexes, sensory changes along cervical dermatome, increased muscle tone or spasticity, bowel or bladder dysfunction, or gait abnormalities
✓
Evaluation of neck pain with failure of 6 weeks conservative treatment, worsening symptoms during treatment, abnormal EMG showing cervical radiculopathy, or pediatric neck pain with red flags
✓
Evaluation of suspected or known cervical myelopathy with progressive symptoms including hand clumsiness, worsening handwriting, difficulty grasping objects, diffuse hand numbness, or increasing balance and ambulation difficulty
✓
Evaluation of known or suspected multiple sclerosis including establishing new baseline before treatment, follow-up imaging during treatment, suspected demyelinating disease, or neuromyelitis optica spectrum disorders
✓
Evaluation of trauma or acute injury with neurologic deficits, underlying spinal abnormalities, worsening symptoms, unable to clinically clear cervical spine per NEXUS or Canadian C-Spine criteria, or when patient is clinically unevaluable
✓
Evaluation of compression fractures with history of malignancy, young patient without trauma history, imaging characteristics concerning for malignancy, new neurologic deficit, or prior to planned surgery
✓
Evaluation of known or suspected primary spinal tumor, metastatic disease to spine, or cancer with new spinal symptoms or findings in tumors that metastasize to spine
✓
Evaluation of known or suspected spinal infection including osteomyelitis or abscess with supporting signs, symptoms, or laboratory findings, or follow-up of infection with worsening parameters
✓
Evaluation of inflammatory disease or atlantoaxial instability including rheumatoid arthritis with neurologic symptoms or subluxation, high-risk disorders affecting atlantoaxial articulation, spondyloarthropathies, or neuroinflammatory conditions such as sarcoidosis or Behcets
✓
Evaluation of spine abnormalities related to immune system suppression including HIV, chemotherapy, leukemia, or lymphoma with supporting signs, symptoms, laboratory, or imaging findings
✓
Evaluation of other specific conditions including tethered cord, spinal dysraphism, Chiari malformation, syrinx or syringomyelia, toe walking with myelopathy signs, trigeminal neuralgia, Horners syndrome with radicular signs, or suspected CSF leak
✓
Preoperative imaging to develop surgical plan or postoperative evaluation for pseudarthrosis, hardware complications, fusion extent after 6 months, surgical infection, new or changing postoperative neurologic deficits, or suspected complications
✓
Further evaluation of inconclusive or indeterminate findings from prior imaging that requires clarification or one follow-up exam to ensure no suspicious interval change
✓
Surveillance or evaluation in known genetic conditions including Down Syndrome with atlantoaxial instability symptoms, LZTR1-related Schwannomatosis, Neurofibromatosis, SMARCA4 and SMARCB1 syndromes, Von Hippel-Lindau, or Marfan Syndrome per specified screening protocols
✓ Extraction Complete
Policy has been processed and stored in the database.