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HEDIS® Use of Imaging Studies for Low Back Pain

Date: 07/08/26

Superior HealthPlan would like to inform providers on the HEDIS® measure Use of Imaging Studies for Low Back Pain (LBP) and how this reinforces evidence-based care. The current standard in low back pain is to avoid routine imaging for uncomplicated LBP within the first 28 days, unless clinical warning signs are present.

Warning signs include:

  • Loss of sensation especially in the groin, buttocks and inner thighs
  • Changes to bladder or bowel function
  • Weakness or numbness in the lower limbs
  • Prolonged corticosteroid use less than 90 consecutive days of corticosteroid treatment
  • Trauma
  • Systemic Illness
  • Unexplained weight loss
  • History of Cancer
  • History of Osteoporosis
  • History of IV drug use

Why Imaging Studies for LBP Matters

  • Improves quality performance by:
    • Reducing unnecessary testing as early imaging in uncomplicated cases often does not improve outcomes.
    • Avoiding downstream complications because incidental findings can lead to potentially unnecessary procedures, cost, and anxiety without clinical benefit.

LBP Measure at a Glance

  • Who is included: Persons 18–75 years of age with a principal diagnosis of LBP.
  • What is measured: The percentage of eligible persons who did NOT have lumbar imaging (plain X-ray, MRI, or CT) within 28 calendar days of the Index Episode Start Date (IESD)
  • How it’s reported: A higher is better as it reflects the percentage of individuals with low back pain who did not receive routine imaging.
  • Intake period: January 1 – December 3 of the measurement year (first eligible LBP encounter defines the Index Episode Start Date (IESD)).
  • Negative history requirement: No LBP diagnosis/encounter in the 180 calendar days prior to the IESD.
  • Please note: Supplemental data is generally not used for numerator compliance (it may be used for denominator exclusions, as allowed).

Imaging for LBP: When to Order Versus When to Wait

For uncomplicated acute LBP,  avoid routine imaging during the first 28 calendar days. Provide conservative care (e.g., patient education, activity as tolerated, appropriate analgesia, and follow-up).

Certain serious underlying conditions can determine whether further imaging is needed. Providers should use clinical judgment and follow their organization’s guidelines. Imaging may be appropriate when clinical warning signs listed above are present.

Providers should document the following to support appropriate imaging:

  • Clinical rationale when imaging is ordered (e.g., neurologic deficit, suspected infection, trauma, malignancy concern).
  • Relevant diagnosis if a member has a condition that warrants imaging, ensure the diagnosis (e.g., osteoporosis, cancer history) is captured on the claim/encounter when appropriate.
  • Conservative management and a follow-up plan including reassessment timeframe, return precautions/red flags for uncomplicated cases.

Please note: Providers should avoid ordering imaging as a precaution during the first 28 days if there are no warning signs.

Questions

If you have questions about HEDIS® measurement, coding, or provider resources related to LBP, please contact your Superior Quality team at SHP.HEDIS@SuperiorHealthPlan.com or your Provider Representative. To access their contact information visit Find My Provider Representative.