About this policy
Jurisdiction: JE Part B. States: California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands. Type: Active LCD
Coverage indications
Provisions in this LCD and related coding article only address Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary procedures for other conditions not included in this LCD. PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients who qualify based on the following criteria: Inclusion criteria (ALL are required) : Acute ( 1-3,10,25,27 Symptomatic ( ONE ): Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score ≥ 8) 4-7 Non-hospitalized with moderate to severe pain (NRS or VAS ≥5) despite optimal non-surgical management (NSM) 10 ( ONE ): Worsening pain Stable to improved pain (but NRS or VAS still ≥5) (with ≥ 2 of the following): Progression of vertebral body height loss > 25% vertebral body height reduction Kyphotic deformity Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17 Continuum of care 10 (Both) All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis education for subsequent treatment as indicated. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program. Exclusion criteria 2,5,8-10 : Absolute contraindication Current back pain is not primarily due to the identified acute or subacute VCF(s). Osteomyelitis, discitis or active systemic or surgical site infection Pregnancy Relative contraindication Greater than three vertebral fractures per procedure Allergy to bone cement or opacification agents Uncorrected Coagulopathy Spinal instability Myelopathy from the fracture Neurologic deficit Neural impingement Fracture retropulsion/canal compromise
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 22510 | CPT | Covered |
| 22511 | CPT | Covered |
| 22512 | CPT | Covered |
| 22513 | CPT | Covered |
| 22514 | CPT | Covered |
| 22515 | CPT | Covered |
| C41.2 | ICD10CM | Covered |
| C79.51 | ICD10CM | Covered |
| C79.52 | ICD10CM | Covered |
| C90.00 | ICD10CM | Covered |
| C90.01 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |