About this policy
Jurisdiction: JJ Part B. States: Alabama, Georgia, Tennessee. Type: Active LCD
Coverage indications
PVA (percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP)) is covered in patients who qualify based on the following criteria : 1. 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) *Consider including pedicle periosteal infiltration 7 c. Continuum of care 10 (BOTH) : All patients presenting with VCF should be referred for evaluation of bone mineral density (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. 2. Exclusion criteria 2,5,8-10 : a. 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 b. Relative contraindication: Allergy to bone cement or opacification agents Uncorrected coagulopathy Spinal instability Myelopathy from the fracture Neurologic deficit Neural impingement Fracture retropulsion/canal compromise Greater than 3 vertebral fractures Vertebral augmentation and kyphoplasty for VCFs with intractable spinal pain not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving a vertebral body.
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 |
| C90.00 | ICD10CM | Covered |
| C90.02 | ICD10CM | Covered |
| M80.08XA | ICD10CM | Covered |
| M80.08XG | ICD10CM | Covered |