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Medical Policy: 06.01.10
Original Effective Date: September 2000
Reviewed: August 2011
Revised: March 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Percutaneous vertebroplasty is an interventional radiology technique. The procedure is performed under local or general anesthesia. A needle is advanced percutaneously under fluoroscopy, computed tomography or both, and polymethylmethacrylate (PMMA), which serves as a bone cement is injected into the weakened or damaged vertebral body. This procedure has been used as a treatment to relieve pain and provide stability for vertebral collapse of the cervical or thoracic region related to osteoporosis, osteolytic vertebral metastases and multiple myeloma related to destruction of the vertebral body, vertebral eosinophilic granuloma with spinal instability or as treatment of aggressive vertebral hemangiomas.
Percutaneous kyphoplasty is a more recently developed variant of vertebroplasty, and it can be done in an open procedure. The principal difference in the case of kyphoplasty is that the fracture itself is at least partially reduced by expanding the intra-body space with the aid of a specialized bone tamp with an inflatable balloon. Once the compression fracture is reduced as much as possible the PMMA is injected. This allows for a degree of the bone deformity and the resulting kyphosis to be reduced, thus offering significant reduction in pain.
Neither vertebroplasty nor kyphoplasty is indicated for the treatment of lesions of the sacrum or coccyx.
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Prior Approval:
Not applicable
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Policy:
Percutaneous vertebroplasty may be considered medically necessary for any one of the following conditions:
- Osteolytic vertebral metastasis or multiple myeloma with severe back pain related to destruction of the vertebral body not involving cortical bone
- Osteoporotic vertebral collapse or compression fractures with persistent pain not responding to standard accepted medical treatment for a period of at least six weeks
- Painful and aggressive vertebral eosinophilic granuloma or hemangiomas (highly vascular lesions) with spinal instability
- Loss of 1/3 of height due to vertebral body collapse with intact posterior wall
- Steroid induced or traumatic vertebral fractures
- As a reinforcement or stabilization of the vertebral body prior to surgery
Percutaneous kyphoplasty may be considered medically necessary for the following conditions:
- Osteolytic vertebral metastasis or multiple myeloma with severe back pain related to destruction of the vertebral body not involving cortical bone
- Osteoporotic vertebral collapse or compression fractures with persistent pain not responding to accepted standard medical treatment for a period of at least six weeks
Accepted standard medical treatment is defined as:
- Initial bed rest with progressive activity; and narcotic or non-narcotic analgesics; and back bracing
- Medical treatment of osteoporosis
Percutaneous vertebroplasty or kyphoplasty are considered not medically necessary for compression fractures that are more than one year old.
Percutaneous vertebroplasty is considered investigational for all other indications, including use in acute vertebral fractures due to osteoporosis or trauma.
Percutaneous kyphoplasty is considered investigational for all other indications, including use in acute vertebral fractures due to osteoporosis or trauma.
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Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 22520 Percutaneous vertebroplasty, one vertebral body; unilateral or bilateral injection; thoracic
- 22521 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar
- 22522 Each additional thoracic or lumber vertebral body
- 22523 Percutaneous vertebral augmentation, one vertebral body, unilateral or bilateral cannulation
- 22524 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); lumbar
- 22525 Each additional thoracic or lumbar vertebral body
- 72291 Radiological supervision and interpretations, percutaneous vertebroplasty or vertebra augmentation including cavity creation, per vertebral body; under fluoroscopic guidance
- 72292 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance
- S2360 for percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection, cervical.
- S2361 each additional cervical vertebral body
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Selected References:
- Jensen ME. Percutaneous vertebroplasty: A new therapy for the treatment of painful vertebral compression fracture. Applied Radiology June 2000; p7-11.
- Martin JB, Jean B, Sugiu K, San Millan Ruiz D, Piotin M, Murphy K, Rufenacht B, Muster M and Rufenacht DA. Vertebroplasty: Clinical experience and follow-up results. Bone 1999;vol25 (2): 11S-15S.
- Cyteval C, Sarrabere MP, Roux JO, Thomas E, Jorgensen C, Blotman F, Sany J, Taourel P. Acute Osteoporotic Vertebral Collapse: Open study on percutaneous injection of acrylic surgical cement in 20 patients. AJR American Journal of Roentgenology 1999;173:1685-1690.
- Medicare part B News Issue 177 Nov. 1999; Entry 5514, Subject: Coverage for Percutaneous Vertebroplasty.
- Garfin SR, Buckley RA, et al. Balloon kyphoplasty for symptomatic vertebral body compression fractures results in rapid, significant, and sustained improvements in back pain, function, and quality of life for elderly patients. Spine. 2006 Sep 1;31(19):2213-20.
- Deen HG, Aranda-Michel J, et al. Balloon kyphoplasty for vertebral compression fractures in solid organ transplant recipients: results of treatment and comparison with primary osteoporotic vertebral compression fractures. Spine J. 2006 Sep-Oct;6(5):494-9. Epub 2006 Jul 24.
- Voormolen MH, Mali WP, et al. Percutaneous vertebroplasty compared with optimal pain medication treatment: short-term clinical outcome of patients with subacute or chronic painful osteoporotic vertebral compression fractures. The VERTOS study. AJNR Am J Neuroradiol. 2007 Mar;28(3):555-60.
- Anselmetti GC, Corrao G, et al. Pain relief following percutaneous vertebroplasty: results of a series of 283 consecutive patients treated in a single institution. Cardiovasc Intervent Radiol. 2007 May-Jun;30(3):441-7.
- Jensen ME, McGraw JK, Cardella JF, Hirsch JA; American Society of Interventional and Therapeutic Neuroradiology; Society of Interventional Radiology; American Association of Neurological Surgeons/Congress of Neurological Surgeons; American Society of Spine Radiology. Position Statement on Percutaneous Vertebral Augmentation: A Consensus Statement Developed by the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, American Association of Neurological Surgeons/Congress of Neurological Surgeons, and American Society of Spine Radiology. AJNR Am J Neuroradiol. 2007 Sep;28(8):1439-43.
- Blue Cross Blue Shield Association Technology Evaluation Center (TEC). Percutaneous vertebroplasty or kyphoplasty for vertebral fractures caused by osteoporosis or malignancy. (2008). TEC Assessments, 23(5):1-36.
- ECRI Institute. Vertebroplasty and Kyphoplasty for Vertebral Fractures. Plymouth Meeting (PA): ECRI Institute; 2009 Oct 15. 17 p. [ECRI hotline response]. Also available: http://www.ecri.org.
- American College of Radiology. Practice guideline for the performance of vertebroplasty. Revised 2009. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/head-neck/percutaneous_vertebroplasty.aspx. Last accessed March 2010.
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Policy History:
Date Reason Action
March 2010 Annual review Revised
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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