485 Percutaneous Kyphoplasty - AAPC

Medical Policy Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation

Table of Contents

Policy: Commercial Policy: Medicare Authorization Information

Coding Information Description Policy History

Information Pertaining to All Policies References Endnotes

Policy Number: 485

BCBSA Reference Number: 6.01.38

Related Policies

Percutaneous Vertebroplasty and Sacroplasty, #484

Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Percutaneous balloon kyphoplasty may be MEDICALLY NECESSARY for the treatment of: Symptomatic osteoporotic vertebral fractures that have failed to respond to conservative treatment

(e.g., analgesics, physical therapy, and rest) for at least 6 weeks Severe pain due to osteolytic lesions of the spine related to multiple myeloma or metastatic

malignancies.

Percutaneous balloon kyphoplasty is INVESTIGATIONAL for all other indications, including use in acute vertebral fractures due to osteoporosis or trauma.

Percutaneous mechanical vertebral augmentation using any other device, including but not limited to Kiva and vertebral body stenting, is INVESTIGATIONAL.

Medicare HMO BlueSM and Medicare PPO BlueSM Members

Indications: Radiographic studies to identify the fracture, estimate the duration of the fracture, define the fracture anatomy, and assess for posterior vertebral body wall deficiency should be part of preoperative planning for vertebroplasty or vertebral augmentation surgery. Lateral radiographs are essential for planning the trajectory of any percutaneous procedure. MRI and bone scan have proven to be useful in determining the acuity of a vertebral compression fracture.

A pathologic fracture is defined as "one due to weakening of the bone structure by pathologic processes, such as neoplasia, osteomalacia, osteomyelitis, and other disease." They are also called "secondary fractures and spontaneous fractures" (Dorland's Illustrated Medical Dictionary 2000; 29th edition). Vertebral compression fractures due to osteoporosis are considered pathologic fractures. A "recent"

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compression fracture is defined as one which demonstrates uptake on a bone scan or exhibits increased intensity on fluid-sensitive MRI sequences.

The principal indications for percutaneous vertebroplasty include: An osteoporotic compression fracture of the lumbar or thoracic vertebrae with persistent debilitating

pain that has not responded to accepted standard medical treatment generally within six (6) weeks to three months; Osteolytic metastasis with severe back pain related to a destruction of the vertebral body; Multiple myeloma with severe back pain related to a destruction of the vertebral body; Painful and/or aggressive vertebral hemangiomas (or eosinophilic granulomas of the spine); Painful vertebral fracture associated with osteonecrosis (Kummell Disease); and Reinforcement, or stabilization, of vertebral body prior to surgery. The principal indications for percutaneous vertebral augmentation include: A "recent" osteoporotic compression fracture of the lumbar or thoracic vertebrae with persistent debilitating pain that has not responded to accepted standard medical treatment; and/or Osteolytic vertebral collapse secondary to multiple myeloma or osteolytic metastatic disease causing persisting or progressive pain.

Limitations: Neither percutaneous vertebroplasty, nor percutaneous vertebral augmentation, are to be considered prophylactic procedures for osteoporosis of the spine. Neither percutaneous vertebroplasty, nor percutaneous vertebral augmentation should be used for chronic back pain of long-standing duration, even if associated with old compression fractures, unless pain is localized to a specific chronic fracture and medical therapy has failed.

The decision for treatment should be multidisciplinary and consider such factors as the extent of disease, the underlying etiology, the spinal level involved, the severity of the pain, the nature of any neurologic dysfunction, the outcome of any previous non-invasive treatment attempts, and the general state of the patient's health.

Absolute contraindications to both percutaneous vertebroplasty and vertebral augmentation procedures include: Any existing uncorrected coagulopathy or anticoagulation therapy; A known allergy to any materials used in the procedure such as the contrast media or bone cement; Ongoing local or systemic infection; Retropulsed bone fragments resulting in spinal canal compromise and myopathy; and Spinal canal compromise secondary to tumor resulting in myelopathy.

Relative contraindications to percutaneous vertebroplasty include: Significant vertebral collapse (i.e., vertebra reduced to less than one-third [l/3] of its original height); Neurologic symptoms related to the compression of the vertebrae; Radiculopathy in excess of vertebral pain caused by a compressive syndrome unrelated to vertebral

collapse; Asymptomatic retropulsion of a fracture fragment causing significant spinal canal compromise; Asymptomatic tumor extension into the epidural space; and/or Extensive vertebral destruction (extreme caution must be used in these patients during cement

injection to prevent new or further neurologic compression that might result from leakage of the acrylic polymer into the epidural space).

Relative contraindications to percutaneous vertebral augmentation include: Painful benign neoplasms; Fractures caused by high-velocity injury; or Other causes of disabling back pain not due to acute fracture.

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Local Coverage Determination (LCD): Vertebroplasty and Vertebral Augmentation (Percutaneous) (L26439) vanced&bc=KAAAAAgAIAAAAA%3d%3d&

Prior Authorization Information

Pre-service approval is required for all inpatient services for all products.

See below for situations where prior authorization may be required or may not be required for outpatient

services.

Yes indicates that prior authorization is required.

No indicates that prior authorization is not required.

Outpatient

Commercial Managed Care (HMO and POS)

Yes

Commercial PPO and Indemnity

Yes

Medicare HMO BlueSM

Yes

Medicare PPO BlueSM

Yes

CPT Codes / HCPCS Codes / ICD-9 Codes

The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

CPT Codes

CPT codes: 22523

22524

22525

72291 72292

Code Description Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); thoracic Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); lumbar Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure) Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance

ICD-9 Diagnosis Codes

ICD-9-CM

diagnosis

codes:

Code Description

170.2

Malignant neoplasm of vertebral column, excluding sacrum and coccyx

198.5

Secondary malignant neoplasm of bone and bone marrow

203.00

Multiple myeloma, without mention of having achieved remission

203.01

Multiple myeloma, in remission

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203.02 338.3 733.13

Multiple myeloma, in relapse Neoplasm related pain (acute) (chronic) Pathologic fracture of vertebrae

ICD-9 Procedure Codes

ICD-9-CM

procedure

codes:

Code Description

81.66

Percutaneous vertebral augmentation

ICD-10 Diagnosis Codes

ICD-10-CM

Diagnosis

codes:

Code Description

C41.2

Malignant neoplasm of vertebral column

C79.51

Secondary malignant neoplasm of bone

C79.52

Secondary malignant neoplasm of bone marrow

C90.00

Multiple myeloma not having achieved remission

C90.01

Multiple myeloma in remission

C90.02

Multiple myeloma in relapse

G89.3

Neoplasm related pain (acute) (chronic)

M48.50xA

Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture

M48.50xD

Collapsed vertebra, not elsewhere classified, site unspecified, subsequent encounter for fracture with routine healing

M48.50xG

Collapsed vertebra, not elsewhere classified, site unspecified, subsequent encounter for fracture with delayed healing

M48.50xS

Collapsed vertebra, not elsewhere classified, site unspecified, sequela of fracture

M48.51xA

Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture

M48.51xD

Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, subsequent encounter for fracture with routine healing

M48.51xG

Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, subsequent encounter for fracture with delayed healing

M48.51xS

Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, sequela of fracture

M48.52xA

Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture

M48.52xD

Collapsed vertebra, not elsewhere classified, cervical region, subsequent encounter for fracture with routine healing

M48.52xG

Collapsed vertebra, not elsewhere classified, cervical region, subsequent encounter for fracture with delayed healing

M48.52xS

Collapsed vertebra, not elsewhere classified, cervical region, sequela of fracture

M48.53xA

Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture

M48.53xD

Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with routine healing

M48.53xG

Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with delayed healing

M48.53xS

Collapsed vertebra, not elsewhere classified, cervicothoracic region, sequela of fracture

M48.54xA

Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture

M48.54xD

Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for

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M48.54xG M48.54xS M48.55xA M48.55xD M48.55xG M48.55xS M48.56xA M48.56xD M48.56xG M48.56xS M48.57xA M48.57xD M48.57xG M48.57xS M48.58xA M48.58xD M48.58xG M48.58xS M80.08xA M80.08xD M80.08xG M80.08xK M80.08xP M80.08xS M80.88xA M80.88xD M80.88xG M80.88xK M80.88xP

fracture with routine healing Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with delayed healing Collapsed vertebra, not elsewhere classified, thoracic region, sequela of fracture Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with routine healing Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with delayed healing Collapsed vertebra, not elsewhere classified, thoracolumbar region, sequela of fracture Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture with routine healing Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture with delayed healing Collapsed vertebra, not elsewhere classified, lumbar region, sequela of fracture Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent encounter for fracture with routine healing Collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent encounter for fracture with delayed healing Collapsed vertebra, not elsewhere classified, lumbosacral region, sequela of fracture Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, subsequent encounter for fracture with routine healing Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, subsequent encounter for fracture with delayed healing Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, sequela of fracture Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion Age-related osteoporosis with current pathological fracture, vertebra(e), sequela Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion

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