Which payers have published criteria for MRI lumbar spine without and with contrast (CPT 72158)?

The imaging guidelines used by Aetna, Anthem BCBS, Cigna, Medicare, UnitedHealthcare include criteria that apply to this study. Whether a specific patient's plan requires prior authorization depends on the plan, so confirm on the payer's portal or by phone before scheduling.

Who reviews prior authorization requests for MRI lumbar spine without and with contrast (CPT 72158)?

Most commercial payers hand imaging reviews to a radiology benefit manager. For the payers tracked here, requests are reviewed using guidelines from eviCore, Carelon, CMS, UnitedHealthcare / eviCore. The request is submitted through that organization's portal rather than the health plan's general line.

What should be in the clinical notes before requesting MRI lumbar spine without and with contrast (CPT 72158)?

Reviewers look for a recent office visit that documents the symptoms and how long they have lasted, exam findings, results of any earlier imaging, treatments already tried and how the patient responded, and the specific question the study is expected to answer. The diagnosis code on the request should match what the notes describe.

What can be done if MRI lumbar spine without and with contrast (CPT 72158) is denied?

Read the denial letter for the stated reason, then request a peer-to-peer conversation between the ordering clinician and the reviewing physician, which often resolves missing-information denials. If that fails, file a written appeal that answers the stated reason directly and attach the supporting notes. The denial letter lists the deadline and where to send the appeal.

CPT 72158: MRI lumbar spine without and with contrast - Prior Authorization and Price

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CPT 72158

MRI lumbar spine without and with contrast.

MRI Spine

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026	56 that name this code
Anthem BCBS	Carelon	Imaging of the spine effective Sep 19, 2026 Oncologic imaging effective Apr 4, 2026	24 that name this code
Cigna	eviCore	Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric Head Imaging Guidelines 2.0.2026, effective Sep 1, 2026	55 that name this code
Medicare	CMS	NCD 220.2: Magnetic Resonance Imaging effective Apr 10, 2018 L34220: Lumbar MRI (Noridian Healthcare Solutions) effective Oct 23, 2025	2 that name this code
Original Medicare does not run a prior authorization program for outpatient imaging; claims are judged against the coverage policies above. Medicare Advantage plans set their own prior authorization rules.
UnitedHealthcare	UnitedHealthcare / eviCore	Commercial and Exchange Cardiovascular and Radiology Imaging Guidelines 09.2026, effective Sep 1, 2026	56 that name this code

Guidelines collected from the payers' published documents on September 29, 2026. Payers revise these documents during the year. Open the guideline link to confirm the current version before you submit.

Conditions the guidelines address for this study

These are the clinical situations where payer guidelines discuss MRI lumbar spine without and with contrast. Each has its own criteria for when the study is considered appropriate.

Primary Central Nervous System Tumors Aetna · Cigna · UnitedHealthcare
Sarcomas – Bone, Soft Tissue, and GIST Aetna · Cigna · UnitedHealthcare
Metastatic Cancer, Carcinoma of Unknown Primary Site, and Other Types of Cancer Aetna · Cigna · UnitedHealthcare
Multiple Myeloma and Plasmacytomas Aetna · Cigna · UnitedHealthcare
CNS Tumors Aetna · Cigna · UnitedHealthcare
Neuroblastoma Aetna · Cigna · UnitedHealthcare
Screening Imaging in Cancer Predisposition Syndromes Aetna · Cigna · UnitedHealthcare
Ataxia Aetna · Cigna · UnitedHealthcare
Chiari and Skull-Base Malformations Aetna · Cigna · UnitedHealthcare
CNS and Head Infection/Neuro-COVID-19 Aetna · Cigna · UnitedHealthcare
Histiocytic Disorders Aetna · Cigna · UnitedHealthcare
Multiple Sclerosis (MS) and Related Conditions Aetna · Cigna · UnitedHealthcare
Pediatric Soft Tissue Sarcomas Aetna · Cigna · UnitedHealthcare
Spinal Dysraphism and Tethered Spinal Cord Aetna · Cigna · UnitedHealthcare
Cerebral Aneurysm and AVM Aetna · Cigna · UnitedHealthcare
Headache Aetna · Cigna · UnitedHealthcare
Imaging Techniques Aetna · Cigna · UnitedHealthcare
Infantile Hemangiomas Aetna · Cigna · UnitedHealthcare
Long Term Pediatric Cancer Survivors Aetna · Cigna · UnitedHealthcare
Macrocephaly, Microcephaly, and Hydrocephalus Aetna · Cigna · UnitedHealthcare
Neuromuscular Disorders Aetna · Cigna · UnitedHealthcare
Paresthesias and/or Weakness Aetna · Cigna · UnitedHealthcare
Pediatric Demyelinating Diseases Aetna · Cigna · UnitedHealthcare
Peripheral Nerve Sheath Tumors (PNST) Aetna · Cigna · UnitedHealthcare
Polyneuropathy Aetna · Cigna · UnitedHealthcare
Retinoblastoma Aetna · Cigna · UnitedHealthcare
Spinal Canal/Cord Disorders (e.g., Syringomyelia) Aetna · Cigna · UnitedHealthcare
Suspected Physical Child Abuse Aetna · UnitedHealthcare
Axial spondyloarthropathy Anthem BCBS
Bone Sarcoma Anthem BCBS
Cancer screening, not otherwise specified Anthem BCBS
Cauda equina syndrome Anthem BCBS
Congenital spinal cord anomalies not listed Anthem BCBS
Congenital vertebral defects Anthem BCBS
Histiocytic Neoplasms Anthem BCBS
Juvenile idiopathic arthritis (Pediatric only) Anthem BCBS
Low back pain or lumbar radiculopathy Anthem BCBS
Lumbar MRI Medicare
Magnetic Resonance Imaging Medicare
Myelopathy Anthem BCBS

Plus 14 more. Use the search below to find a specific condition.

Typical price

Commercial insurance, median

$1,550

Middle half of rates: $783 to $3,076

Medicare, hospital outpatient

$356

Facility payment

Medicare, physician fee schedule

$320

National, non-facility

Commercial figures come from negotiated rates published by 1,063 hospitals; Medicare figures from CMS fee schedules. Rates vary widely by hospital and plan. Pricing data from CenterIQ.

Get notified when the rules for this study change

Payers update imaging guidelines several times a year. We will email you when the criteria for MRI lumbar spine without and with contrast change.

CPT 72158: MRI lumbar spine without and with contrast - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

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CPT 72158: MRI lumbar spine without and with contrast - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

Related studies

Imaging CPT Code Coverage Lookup

Quick Access - Common Imaging CPT Codes

CT

MRI

MRA

PET