Medical Policy
Effective Date:12/16/2003 Title:Percutaneous Vertebroplasty & Kyphoplasty
Revision Date:10/01/2015 Document:BI018:00
CPT Code(s):22510-22515
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Percutaneous Vertebroplasty and Kyphoplasty require preauthorization.

2)    Percutaneous Vertebroplasty is a method of treating the pain of vertebral compression fractures, especially due to Osteoporosis. It involves injecting liquid plastic into the vertebral body. When the plastic hardens, it stabilizes the fracture and reduces the pain.

3)    Percutaneous Kyphoplasty is a technique designed to restore the lost height of a fractured vertebral body prior to stabilization with liquid plastic, as in a Vertebroplasty.

Medical Statement
  1. Percutaneous Polymethylmethacrylate Vertebroplasty (PPV) or Kyphoplasty is considered medically necessary for members with persistent, debilitating pain in the cervical, thoracic or lumbar vertebral bodies resulting from any of the following:

·       Multiple myeloma (C90.00-C90.02); or

·       Painful and/or aggressive hemangiomas (D18.09); or

·       Painful vertebral eosinophilic granuloma (C96.6) ; or

·       Painful, debilitating osteoporotic collapse/compression fractures (e.g., Kummell`s disease) (M80.08XA – M80.08XS); or

·       Primary malignant neoplasm of bone or bone marrow (C41.2); or

·       Secondary osteolytic metastasis, excluding sacrum and coccyx (M84.58XA – M84.58XS); or

·       Steroid-induced fractures (M84.48XA – M84.48XS or M84.68XA – M84.68XS)

AND all of the following criteria have been met:

·       Other causes of pain such as herniated intervertebral disk have been ruled out by computed tomography or magnetic resonance imaging; and

·       Severe debilitating pain or loss of mobility that cannot be relieved by optimal medical therapy of at least 6 weeks (e.g., acetaminophen, non-steroidal anti-inflammatory drugs [NSAIDS], narcotic analgesics, braces, physical therapy, etc.); and

·       The affected vertebra has not been extensively destroyed and is at least one-third of its original height.

Not considered medically necessary in treatment of acute spinal fractures.

Codes Used In This BI:

22510           Percut Vertebroplasty Thor

22511           Percut Vertebroplasty Lumb

22512           Percut Vertebroplasty Addl

22513           Percut Kyphoplasty Thor

22514           Percut Kyphoplasty Lumbar

22515           Percut Kyphoplasty Add-On

2510-22515-1-15)h the following ICD-10

Limits
Intentially left empty
Reference

1.     Alberta Heritage Foundation for Medical Research (AHFMR). Vertebroplasty. Edmonton, AB: AHFMR; 1999.

2.     National Institute for Clinical Excellence. . Percutaneous vertebroplasty. IP Guidance Number: IPG0012. London, UK: NICE; September 2003. Available at: http://www.nice.org.uk/page.aspx?c=56770 .

3.     Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial outcome and efficacy of `kyphoplasty` in the treatment of painful osteoporotic vertebral compression fractures. Spine. 2001; 26:1631-1638.

4.     Dudeney S, Lieberman IH, Reinhardt MK, Hussein M. Kyphoplasty in the treatment of osteolytic vertebral compression fractures as a result of multiple myeloma. J Clin Oncol. 2002; 20(9):2382-2387.

5.     Canadian Coordinating Office of Health Technology Assessment (CCOHTA). Percutaneous vertebroplasty: A bone cement procedure for spinal pain relief. Issues in Emerging Health Technologies. Issue 31. Ottawa, ON: CCOHTA; May 2002.

6.     Institute for Clinical Systems Improvement (ICSI). Vertebroplasty and balloon-assisted vertebroplasty for the treatment of osteoporotic compression fractures. Technology Assessment Report #79. Bloomington, MN: ICSI; January 2004. Available at: http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=1355

7.     National Institute for Clinical Excellence. Balloon kyphoplasty for vertebral compression fractures. Interventional Procedure Guidance 20. London, UK: NICE; November 2003. Available at: http://www.nice.org.uk/page.aspx?o=91588

8.     U.S. Food and Drug Administration (FDA), Center for Devices and Radiological Health (CDRH). Complications related to the use of bone cement and bone void fillers in treating compression fractures of the spine. FDA Public Health Web Notification. Rockville, MD: FDA; updated May 7, 2004. Available at: http://www.fda.gov/cdrh/safety/bonecement.html .

9.     BlueCross BlueShield Association (BCBSA), Technology Evaluation Center (TEC). Percutaneous kyphoplasty for vertebral fractures caused by osteoporosis and malignancy. Technology Assessment Program. Chicago, IL: BCBSA; December 2004; 19(12). Available at: http://www.bcbs.com/tec/vol19/19_13.html  

10. Arkansas BlueCross BlueShield Coverage Policy Manual; Kyphoplasty, percutaneous at: http://www.arkbluecross.com/members/ex_report.asp?ID=2003024

11. Hayes Medical technology Directory, updated 3/11/2011

Key words:

Vertebroplasyt

Kyphoplasty

Methyl Methacrylate – Vertebroplasy or Kyphoplasty

22520-22525 – Percutaneous Vertebroplasty or Kyphoplasty

Percutaneous Vertebroplasty orKyphoplasty

Spine Fracture – Percutaneous Vertebroplasty or Kyphoplasty

@ BI018

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.