CommercialPrior AuthHigh impact
Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) of the Spine (CPB 0236, reviewed 2026-04-09)
Aetna·Radiology, Neurology, Neurosurgery +4 more·Radiology
Effective date
Apr 9, 2026
We identified it
Aug 19, 2026
Summary
Aetna updated its Clinical Policy Bulletin 0236 for spine MRI/CT imaging, effective immediately (reviewed 2026-04-09). The policy establishes specific medical necessity criteria for coverage of spine imaging and designates BoneMRI (MRI-based synthetic CT), dynamic-kinetic MRI, dual-energy CT, and routine post-CT MRI in certain trauma scenarios as experimental/investigational and therefore non-covered. Billing teams must ensure claims include documented medical necessity meeting one of the listed criteria or face denial.
Action Required
Immediately (effective 2026-04-09): (1) Billing team must implement precertification verification for spine MRI/CT codes (72125-72158, 76390) by querying Aetna's CPT code search tool to identify which procedures require prior authorization; (2) Update billing system to block or flag claims for experimental procedures including BoneMRI (G0566), dynamic-kinetic cervical MRI, dual-energy CT, and routine MRI following normal cervical CT in trauma cases, with denial reason codes; (3) Providers and clinical staff must document one specific qualifying criterion from the 17 listed medical necessity categories on all spine imaging orders (e.g., 'clinical evidence of spinal stenosis' or 'persistent back pain with radiculopathy after 6 weeks conservative therapy'); (4) Encounter forms and EHR templates must be updated to include checklist of Aetna's covered indications; (5) Front desk staff must confirm precertification is obtained before scheduling or claims will be denied. Non-compliance will result in automatic claim denials for missing prior authorization or undocumented medical necessity.