L29209-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation (Vertebral Augmentation) (formerly Kyphoplasty) (L29209)

Contractor Information

Contractor Name First Coast Service Options, Inc

Contractor Number 09102

Contractor Type

MAC - Part B

LCD Information

Document Information

LCD ID Number L29209

LCD Title Percutaneous Vertebral Augmentation (Vertebral Augmentation) (formerly Kyphoplasty)

Contractor's Determination Number 22523

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 03/09/2010

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: N/A

Indications and Limitations of Coverage and/or Medical Necessity

Percutaneous vertebral augmentation (vertebral augmentation) is a minimally invasive procedure for the treatment of compression fractures of the vertebral body. The procedure includes a cavity creation which results in fracture reduction along with an attempt to restore vertebral body height and alignment. The collapsed vertebral body is drilled and a device which displaces, removes or compacts the compressed area of the vertebrae is used to create a cavity prior to injection of a bone filler (polymethylmethacrylate)(PMMA).

Medicare will consider the performance of a vertebral augmentation procedure medically reasonable and necessary for the following indications:

• Painful osteolytic vertebral body metastatic disease;

• Painful multiple myeloma involving the vertebral body;

• Painful, debilitating osteoporotic vertebral body compression fractures(VCFs)that have not responded to conservative medical treatment (e.g., 2-4 week period of immobilization such as restricted activity/bracing and analgesia/scheduled narcotic usage); and

• Severe pain and functional debilitation related to activities of daily living due to chronic VCFs that require hospitalization for pain control and treatment. Conservative medical management is not considered appropriate for such patients. It is expected that this circumstance will occur rarely to occasionally.

The decision to perform this procedure should take into consideration the following factors: the local and general extent of the disease, the spinal level involved, the severity of pain experienced by the patient, previous treatments and their outcomes, as well as the patient’s neurological condition, general state of health, and life expectancy. It is expected that only those skilled in this procedure/technique will perform it. Rapid access to emergency equipment and personnel is required for vertebral augmentation.

The vertebral augmentation procedure is contraindicated in non-painful stable VCFs, clinically improving VCFs, osteomyelitis, uncorrectable coagulopathy, allergy to the PMMA, retropulsed fracture fragment(s) or tumor mass causing significant spinal canal compromise, or when it is technically not feasible (e.g., vertebra plana).

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION 22523 AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY,

UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); THORACIC

22524

PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); LUMBAR

PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION 22525 AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY,

UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); EACH ADDITIONAL THORACIC OR

LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY, VERTEBRAL 72291 AUGMENTATION, OR SACRAL AUGMENTATION (SACROPLASTY), INCLUDING CAVITY CREATION, PER

VERTEBRAL BODY OR SACRUM; UNDER FLUOROSCOPIC GUIDANCE

RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY, VERTEBRAL 72292 AUGMENTATION, OR SACRAL AUGMENTATION (SACROPLASTY), INCLUDING CAVITY CREATION, PER

VERTEBRAL BODY OR SACRUM; UNDER CT GUIDANCE

ICD-9 Codes that Support Medical Necessity

170.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

203.00 - 203.02 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MULTIPLE MYELOMA, IN RELAPSE

238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS

733.13 PATHOLOGICAL FRACTURE OF VERTEBRAE

805.2 CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY

805.4 CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation (e.g., office/progress notes, procedure notes) must indicate the medical necessity for performing this service. The documentation must also support that the service was performed.

When the service is performed for painful, debilitating, osteoporotic VCFs, documentation must support that conservative treatment has failed, unless the patient experienced severe pain and functional limitation in performing activities of daily living due to chronic VCFs and required hospitalization for pain control and treatment. Under those circumstances, documentation must support the severity of pain and functional limitations related to performance of activities of daily living requiring hospitalization.

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Baker, Barbara (2000). New technique eases painful vertebral fractures. OB/GYN News. Available at www.findarticles.com

Cahaba Government Benefit Administrators, LLC. LCD (L30062) for Vertebral augmentation and vertebroplasty. Effective December 1, 2009. Retrieved from http://www.cms.hhs.gov/mcd/search.asp on January 28, 2010.

Grohs, J. G., Matzner, M., Krepler, P. (2004). Minimal invasive stabilization of osteoporotic vertebral Fractures. Journal of Bone and Joint Surgery. Available at www.findarticles.com

Jensen, M.E., McGraw, J.K., et al. (2007). Position Statement on Percutaneous Vertebral Augmentation: A consensus statement developed by the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, American Association of Neurological Surgeons/Congress of Neurological Surgeons and American Society of Spine Radiology.American Journal of Neuroradiology. 28:1439-1443

Kochan, J.P. (2009) Vertebroplasty and kyphoplasty, percutaneous. Retrieved from http://emedicine.medscape.com/article/423209-overview on January 28, 2010.

Lieberman, I.H., Dudeney, S., Reinhardt, M.K., & Bell, G. (2001). Initial outcome and efficacy of “kyphoplasty” in the treatment of osteoporotic vertebral compression fractures. Spine, 26 (14): 1631-1638. Provided the indications of coverage for kyphoplasty.

National Heritage Insurance Company, Corp.(NHIC). LCD (L11417) for Percutaneous Vertebroplasty/ Percutaneous Augmentation. Effective February 1, 2010. Retrieved from http://www.cms.hhs.gov/mcd/search.asp on January 28, 2010.

Noridian Administrative Services, LLC. LCD (L23888) for Vertebroplasty, vertebral augmentation (formerly kyphoplasty); Percutaneous. Effective January 1, 2010. Retrieved from http://cms.hhs.gov/mcd/search.asp on January 28, 2010.

Percutaneious Vertebral Augmentation vs. Percutaneous Vertebroplasty A coding and billing reference guide. Retrieved from www.sofamordanek.com on January 28, 2010.

Tanner, S Bobo (2003). Back pain, vertebroplasty and kyphoplasty: Treatment of Osteoporotic Vertebral Compression Fractures. Bulletin on Rheumatic Diseases. Available at www.findarticles.com

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with the advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 04/01/2010

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:04/01/2010 Revised Effective Date: 03/09/2010

LCR B2010-031

March 2010 Update

Explanation of Revision: Revision of LCD to replace all references to kyphoplasty/balloon kyphoplasty with the generic term “percutaneous vertebral augmentation/vertebral augmentation’’. Title changed from “Kyphoplasty” to “Percutaneous vertebral augmentation (vertebral augmentation)”. Updated the “Sources of Information and Basis for Decision” section of the LCD. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2010

Revised Effective Date: 01/01/2010

LCR B2010-002

December 2009 Update

Explanation of Revision: Annual 2010 HCPCS Update. Revised descriptor for CPT codes 72291 and 72292. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29209) replaces LCD L5762 as the policy in notice. This document (L29209) is effective on 02/02/2009.

11/15/2009 - The description for CPT/HCPCS code 22523 was changed in group 1 11/15/2009 - The description for CPT/HCPCS code 22524 was changed in group 1 11/15/2009 - The description for CPT/HCPCS code 22525 was changed in group 1 11/15/2009 - The description for CPT/HCPCS code 72291 was changed in group 1 11/15/2009 - The description for CPT/HCPCS code 72292 was changed in group 1

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

22523 descriptor was changed in Group 1 22524 descriptor was changed in Group 1 22525 descriptor was changed in Group 1 72291 descriptor was changed in Group 1 72292 descriptor was changed in Group 1

Reason for Change