Update: Lower Back Pain Imaging – Policy Update Effective June 18, 2023

Update September 20: To help alleviate confusion, we have included the following example for our Lower Back Pain (LBP) Imaging Policy Update Effective June 18, 2023:

As an example, a member may suffer with uncomplicated lower back pain for more than 28 days before seeing a provider for the first time. In this scenario, the provider would be correct to append a KX modifier on the imaging service to attest to uncomplicated lower back pain lasting more than 28 days regardless of when the diagnosis was actually made.

The Choosing Wisely® initiative evaluate usage of health care services with a goal of reducing excessive tests and procedures that result in unnecessary medical expense. Subject matter experts and specialty societies provide recommendations for preventing overuse of health care services having a potentially negative impact on both the quality and/or cost of health care.

Lower Back Pain (LBP) Imaging Policy Update Effective June 18, 2023:

• Imaging services (X-ray, CT scan, or MRI) billed within 28 days of a principal diagnosis of uncomplicated LBP are not eligible for reimbursement.
• Imaging services may be appended with a KX modifier to indicate NCQA HEDISTM exclusionary criteria was met.
  • Examples of exclusionary criteria include, but are not limited to; members with a diagnosis of cancer, recent trauma, or uncomplicated lower back pain lasting more than 28 days

Please visit the related previous communication.

View the Reimbursement Policy (PDF).

This communication applies to State Health Plan (SHP), Federal Employee Program (FEP), Administrative Services Only (ASO), Fully Insured, and Blue Card host claims. It does not apply to Blue Card home claims.