Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



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
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
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.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.