Low Back Imaging
One of the reasons for implementation of NIA precertification of imaging is a requirement by the Defense Health Agency that all imaging for uncomplicated low back pain within the first six weeks of incidence be conducted only if it meets the conditions for medical necessity. This requirement follows similar criteria to the NCQA HEDIS measure for imaging for low back pain, in that imaging should only be done if any “red flags” are present.
Red flags are defined as:
- Possible fracture, such as from a major trauma, or a more minor trauma in older or potentially osteoporotic patients
- History of osteoporosis
- Chronic steroid use
- Possible tumor, cancer, or infection, as evidenced by a history of cancer
- A history of intravenous drug use
- Fevers, chills, or unexplained weight loss
- Immune suppression
- Possible cauda equina syndrome, as evidenced by bowel or bladder dysfunction or saddle anesthesia (loss of sensation in the buttocks, perineum, and inner surfaces of the thighs)
- Major motor weakness
- Progressive neurological symptoms
Claims processed for low back pain imaging will include messaging consistent with this new requirement.
