Clinical UM Guideline

This document addresses the use of dynamic spinal visualization, digital motion x-ray, cineradiography or videofluoroscopy, to produce moving images of the spine for the detection or evaluation of structural or functional abnormalities.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Not Medically Necessary:

Dynamic spinal visualization, including, but not limited to, digital motion x-ray of the spine, with or without digitization of spinal x-rays and computerized analysis of the back or spine, is considered not medically necessary for all indications.

Dynamic spinal visualization, including, but not limited to, cineradiography, also known as videofluoroscopy, when used to visualize movement of the back or spine, is considered not medically necessary for all indications.

This document describes clinical studies and expert recommendations, and explains why we consider dynamic spinal visualization, including digital motion x-ray, cineradiography or videofluoroscopy, not clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Dynamic spinal visualization includes tests like digital motion x-ray, cineradiography, and videofluoroscopy. These tests create images of the spine while a person is moving rather than in a fixed position as in a standard x-ray. They aim to help find problems with the bones, discs, or ligaments in the back. At this time, they are not considered clinically appropriate for any use because studies have not shown that they improve health or lead to better care compared to standard imaging tests. Since these tests do not produce medical benefits, the potential harm from prolonged exposure to radiation is an unnecessary risk.

What the Studies Show

Dynamic spinal visualization uses a series of x-ray images to create a video of how the spine moves. Digital motion x-ray takes many images in sequence and turns them into a video. Cineradiography, also called videofluoroscopy, creates real-time video using x-ray technology. These tests are meant to help doctors see how the spine moves and look for problems that may not show up on still images.

Research on these tests is very limited. Only a few small studies have been done. Some results suggest there could be benefits, but larger and better studies are needed to know if these tests improve health. There is also no clear proof that these tests work better than standard imaging methods already in use. Because they rely on repeated x-rays, they may expose people to more radiation without clear benefit.

Is this Clinically Appropriate?

Dynamic spinal visualization, including digital motion x-ray, cineradiography, and videofluoroscopy, is not appropriate because it has not been proven to improve health. Studies so far have included very small numbers of people and do not show that these tests lead to better diagnosis or treatment. Better studies are needed to know if these tests improve health. These tests also expose people to radiation, which adds risk without clear benefit.

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The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Not Medically Necessary:
For the following procedure and diagnosis codes, or when the code describes a procedure indicated in the Clinical Indications section as not medically necessary.

Summary

At this time, the data is insufficient to support the use of dynamic spinal visualization, including digital motion x-rays, cineradiography, and videofluoroscopy of the spine for any indication. Although these technologies can produce real-time or sequential images showing spinal structures in motion, and early studies suggest they may detect abnormalities not visible on static imaging, the existing research is limited to small, low-quality studies. There is not enough evidence to demonstrate that their use improves diagnostic accuracy, changes member management, or leads to better health outcomes compared with standard imaging methods. Additionally, there is insufficent evidence providing a positive risk benefit ratio related to the exposure to the ionizing radiation from x-rays these technologies require. Larger, well-designed controlled trials are needed to establish their clinical value and determine whether they offer meaningful advantages over currently accepted approaches.

Discussion

Dynamic spinal visualization is a general term addressing the use of several different imaging technologies, including digital motion x-ray, cineradiography, and videofluoroscopy. These technologies allow the simultaneous visualization of movement of internal body structures, such as the skeleton, intervertebral discs and ligaments, with corresponding external body movement. All of these methods use x-rays to create images either digitally or on film, to allow visualization of internal structures while an individual is moving. These technologies have been proposed for the evaluation of back pain, orthopedic issues, and other conditions.

Digital motion x-ray involves the use of either film x-ray or computer-based x-ray ‘snapshots’ taken in sequence as an individual moves in front of an x-ray camera. Film x-rays are digitized into a computer for manipulation while computer-based x-rays are automatically created in a digital format. The digitized snapshots are then put in order using a computer program and played on a video monitor, creating a moving image of the inside of the body. This moving image can then be evaluated by a physician alone or by using a computer that evaluates several aspects of the body’s structure to determine the presence or absence of abnormalitites.

Videofluoroscopy and cineradiography are different names for the same procedure that uses fluoroscopy to create real-time video images of internal body structures. Videofluroscopy works like a video camera, providing motion pictures of the inside of the body. The results of these techniques can be displayed on a video monitor as the procedure is being conducted. They can also be viewed or digitally analyzed at a later time.

In 2019, the American College of Occupational and Environmental Medicine (ACOEM) issued a practice guideline for Diagnostic Tests for Low Back Disorders (Hegmann, 2019) in which they state:

Videofluoroscopy has been used for evaluation of LBP, particularly searching for possible spinal instability. There are two low-quality studies. There are no quality studies demonstrating improved clinical outcomes and, therefore, videofluoroscopy for the assessment of acute, subacute, or chronic LBP is not recommended (Not Recommended, Insufficient Evidence (I), Moderate Confidence).

In 2019, the American College of Radiology (ACR) published their ACR Appropriateness Criteria^® Suspected Spine Trauma (Beckmann, 2019) in which they state “The literature has been uniformly negative in assessing the utility of static flexion-extension radiographs or dynamic fluoroscopy for detection of cervical spine ligamentous injuries.”

The ACR published their ACR Appropriateness Criteria^® Cervical Pain or Cervical Radiculopathy in 2025 (Eldaya, 2025). The document does not specifically mention dynamic visualization or videofluoroscopy and makes no recommendation for them.

The current literature evaluating the clinical utility of dynamic spinal visualization techniques, including but not limited to digital motion x-ray and cineradiography (videofluoroscopy), for the evaluation and assessment of the spine is limited to a few studies involving very small numbers of participants. While these studies do indicate that there may be some benefit from the use of these technologies, further evidence from large controlled trials is needed to demonstrate that the results have significant impact on clinical care and are superior to currently available alternatives. Additionally, these technologies involve the use of x-rays and require exposure to inoizing radiation

Cineradiography (also known as Videofluoroscopy): A radiological procedure that uses fluoroscopy, an x-ray procedure, to make it possible to see structures in the body in real-time; this procedure has been proposed as a tool to diagnose or evaluate disease or injuries of the spine.

Digital motion x-ray: A technology in which successive x-rays are digitized and sequenced to create a video representation of movement of internal body structures.

Digitization: The process by which information is transformed from analog format into digital computer-based format.

Peer Reviewed Publications:

1. Harvey S, Hukins D, Smith F, et al. Measurement of lumbar spine intervertebral motion in the sagittal plane using videofluoroscopy. J Back Musculoskelet Rehabil. 2015; 29(3):445-457.
2. Hino H, Abumi K, Kanayama M, Kaneda K. Dynamic motion analysis of normal and unstable cervical spines using cineradiography. An in vivo study. Spine (Phila Pa 1976). 1999; 24(2):163-168.
3. Lindgren KA, Leino E, Manninen H. Cervical rotation lateral flexion test in brachialgia. Arch Phys Med Rehabil. 1992; 73(8):735-737.
4. Okawa A, Shinomiya K, Komori H, et al. Dynamic motion study of the whole lumbar spine by videofluoroscopy. Spine (Phila Pa 1976). 1998; 23(16):1743-1749.
5. Teyhen DS, Flynn TW, Childs JD, et al. Fluoroscopic video to identify aberrant lumbar motion. Spine. 2007; 32(7):E220-E229.
6. Wong KW, Leong JC, Chan MK, et al. The flexion-extension profile of lumbar spine in 100 healthy volunteers. Spine (Phila Pa 1976). 2004; 29(15):1636-1641.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Expert Panel on Neurological Imaging and Musculoskeletal Imaging, Beckmann NM, Clark West O, Nunez Jr D, et al. ACR Appropriateness Criteria^® suspected spine trauma. J Am Coll Radiol. 2019; 16(5S):S264-S285.
2. Expert Panel on Neurological Imaging; Eldaya RW, Parsons MS, Hutchins TA, et al. ACR Appropriateness Criteria^® cervical pain or cervical radiculopathy: 2024 Update. J Am Coll Radiol. 2025; 22(5S):S136-S162.
3. Hegmann KT, Travis R, Belcourt RM, et al. Diagnostic tests for low back disorders. J Occup Environ Med. 2019; 61(4):e155-e168.

1. National Institute of Neurological Disorders and Stroke. Pain. Last reviewed March 13, 2026. Available at: https://www.ninds.nih.gov/health-information/disorders/back-pain. Accessed on March 18, 2026.
2. National Library of Medicine. Health topics: back pain. Last updated June 29, 2025. Available at: http://www.nlm.nih.gov/medlineplus/backpain.html. Accessed on March 18, 2026.

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