Low Back Pain Imaging
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.
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.
When submitting claims for LBP imaging, 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 are required fields. Claims received without these fields may be denied.