Benefit Update: Diagnostic Imaging for Low Back Pain
Wednesday, December 30, 2020
Retroactive to Oct. 30, 2020, and implemented on Dec. 30, 2020, TRICARE no longer covers diagnostic imaging for TRICARE beneficiaries with acute low back pain (LBP) within six weeks of the onset of symptoms in an otherwise healthy patient.
Based on Healthcare Effectiveness Data and Information Set® (HEDIS®) research developed by the National Committee for Quality Assurance (NCQA), otherwise healthy patients with new onset LBP diagnosis should not receive any imaging, including X-rays, ultrasound, CT scans, and MRIs, within the first six weeks of diagnosis. Instead, a more conservative treatment approach including medication and physical therapy should be considered.
The Defense Health Agency (DHA) realizes that each patient’s presentation is unique, and that in some cases, delaying imaging for six weeks may not be appropriate. Therefore, DHA has identified the following medical conditions where imaging could be considered medically necessary on initial patient presentation:
- Possible fracture
- Possible tumor, cancer or infection
- Possible cauda equina syndrome
- Major motor weakness
- Progressive neurological symptoms.
It is important when submitting claims for LBP imaging to include appropriate, specific diagnosis codes indicating medical necessity, when required. The ‘Date of current illness or injury’ (Professional claim form) with qualifier 431 and ‘Onset of current symptoms or illness’ (institutional claim form) with qualifier BH will be required fields. Claims received without these fields may be denied.