Horizon BCBS NJ MRI Lumbar Spine without contrast prior authorization requirements (2026)
What Horizon BCBS NJ generally requires to approve MRI Lumbar Spine without contrast (CPT 72148), for PPO plans. Yes. Horizon BCBS NJ generally requires prior authorization for MRI Lumbar Spine without contrast (CPT 72148).
Medical-necessity criteria Horizon BCBS NJ generally applies
Prior authorization required; Horizon commercial outpatient advanced imaging is managed by eviCore (EviCore by Evernorth) - some self-insured/ASO groups route to Carelon instead. Per eviCore's Spine Imaging Guidelines (V1.1.2025, eff 2/14/2025), MRI of the lumbar spine for non-red-flag low back pain requires: an in-person clinical evaluation for the current episode with a detailed neurologic exam (manual motor strength grade, dermatomal sensory testing, reflexes, nerve-root tension signs such as straight-leg raise); documented failure of a recent (within 12 weeks) 6-week trial of provider-directed conservative treatment; and a clinical re-evaluation after that trial. Red-flag indications (new motor weakness grade <=3/5 or new foot drop, cauda equina syndrome, suspected fracture, infection, cancer, severe radicular pain, aortic aneurysm/dissection) bypass the 6-week conservative-care requirement. Suspected or documented myelopathy is imaged in the initial evaluation. CT or CT myelography is appropriate only when MRI is contraindicated. Pre-surgical/pre-procedural planning is a covered indication. Thresholds quoted from the eviCore guideline.
Related procedure codes
Codes often billed alongside MRI Lumbar Spine without contrast: 72148, 72158. Verify the correct codes for your documentation.
Commonly required documentation
- In-person evaluation note for the current episode
- detailed neurologic exam (strength grade, dermatomal sensory, reflexes, nerve-root tension signs)
- documentation of the 6-week provider-directed conservative trial and the post-trial re-evaluation
- any red-flag findings
- relevant prior/plain imaging where applicable.
Situations to verify before submitting
Horizon BCBS NJ may not cover MRI Lumbar Spine without contrast in these situations. Verify against the current policy rather than assuming a denial:
- Early MRI for uncomplicated, non-red-flag acute low back pain that has not failed a documented 6-week conservative trial - not medically necessary per eviCore SP criteria (ACR Appropriateness Criteria basis)
- CT or CT myelography in place of MRI when MRI is not contraindicated
- Requests lacking an in-person evaluation, documented conservative-care failure, or post-trial re-evaluation (absent a red flag)
How to submit
- Method: portal
- Portal: eviCore (EviCore by Evernorth) Provider Portal
Sources & verification
- BindingeviCore — eviCore Spine Imaging Guidelines (Horizon commercial radiology benefit manager) (SP V1.1.2025) · effective 2025-02-14.View
- BindingPayer medical policy — Horizon Radiology / Imaging Services program (eviCore).View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-06-19.
Frequently asked questions
Does Horizon BCBS NJ require prior authorization for MRI Lumbar Spine without contrast?
Yes. Horizon BCBS NJ generally requires prior authorization for MRI Lumbar Spine without contrast (CPT 72148).
What does Horizon BCBS NJ require to approve MRI Lumbar Spine without contrast?
Prior authorization required; Horizon commercial outpatient advanced imaging is managed by eviCore (EviCore by Evernorth) - some self-insured/ASO groups route to Carelon instead. Per eviCore's Spine Imaging Guidelines (V1.1.2025, eff 2/14/2025), MRI of the lumbar spine for non-red-flag low back pain requires: an in-person clinical evaluation for the current episode with a detailed neurologic exam … Always confirm against the current Horizon BCBS NJ policy.
How long does a Horizon BCBS NJ prior authorization take?
Turnaround varies by plan and submission method. Check the Horizon BCBS NJ portal for current timeframes.
Submitting MRI Lumbar Spine without contrast to Horizon BCBS NJ?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.