Criteria library
600+ payer policies, continuously refreshed and version-tracked. Each criterion links to its source.
Magnetic Resonance Imaging — Lumbar Spine
Documented low back pain or radicular symptoms persisting ≥6 weeks despite conservative management, OR presence of red-flag findings (cauda equina, progressive neuro deficit, suspected malignancy/infection, significant trauma).
Documentation of supervised physical therapy, NSAIDs, activity modification, or equivalent ≥6 weeks. Waived if red flags present.
Physical exam documents focal deficit (motor, sensory, reflex) consistent with imaging hypothesis, OR PA submitted in context of planned procedure.
Member has not had MRI of same anatomic region within 12 months unless clinically significant change documented.
Order placed by NPI in good standing with active license in member's state.