Percutaneous Vertebroplasty and Kyphoplasty* Printer-Friendly Version   

Medical Policy: 06.01.10 
Original Effective Date: September 2000 
Reviewed: August 2007 
Revised: March 2002 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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 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.

Policy: 

Percutaneous vertebroplasty may be considered medically necessary for any one of the following conditions:

• Osteolytic vertebral metastasis and 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 and 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.  

Prior approval is recommended for this service. Submit a prior approval now.

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Procedure Codes and Billing Guidelines: 

To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.

• CPT 22520 Percutaneous vertebroplasty, one vertebral body; unilateral or bilateral injection; thoracic
• CPT 22521 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar 
• CPT 22522 Each additional thoracic or lumber vertebral body
• CPT 22523 Percutaneous vertebral augmentation, one vertebral body, unilateral or bilateral cannulation
• CPT 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 
• CPT 22525 Each additional thoracic or lumbar vertebral body 
• CPT 72291 Radiological supervision and interpretations, percutaneous vertebroplasty or vertebra augmentation including cavity creation, per vertebral body; under fluoroscopic guidance
• CPT 72292 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance 
• HCPCS S2360 for percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection, cervical.
• HCPCS S2361 each additional cervical vertebral body

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Selected References: 

• A review of the medical literature and recommendations from Wellmark’s Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies.  The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
• 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. 

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Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Prior Approval is recommended for this policy.

**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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.