LCD/NCD Portal

L29209 PERCUTANEOUS VERTEBRAL AUGMENTATION (VERTEBRAL AUGMENTATION) (FORMERLY KYPHOPLASTY)

 

 

03/09/2010

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

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

o 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.

o 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:

o The local and general extent of the disease.

o The spinal level involved.

o The severity of pain experienced by the patient.

o Previous treatments and their outcomes, as well as the patient’s:

 Neurological condition.

 General state of health.

 Life expectancy.

• It is expected that only those skilled in this procedure/technique will perform it.

o Rapid access to emergency equipment and personnel is required for vertebral augmentation.

 

• The vertebral augmentation procedure is CONTRAINDICATED in:

o Non-painful stable VCFs.

o Clinically improving VCFs.

o Osteomyelitis.

o Uncorrectable coagulopathy.

o Allergy to the PMMA.

o Retropulsed fracture fragment(s).

o Tumor mass causing significant spinal canal compromise.

o When it is technically not feasible (e.g., vertebra plana).

 

 

CPT/HCPCS Codes

 

22523 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); 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

22525 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); EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

72291 RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY, VERTEBRAL AUGMENTATION, OR SACRAL AUGMENTATION (SACROPLASTY), INCLUDING CAVITY CREATION, PER VERTEBRAL BODY OR SACRUM; UNDER FLUOROSCOPIC GUIDANCE

72292 RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY, VERTEBRAL 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 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.01 MULTIPLE MYELOMA IN REMISSION

203.02 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

 

 

Documentation Requirements

• Medical record documentation (e.g., office/progress notes, procedure notes) must indicate the medical necessity for performing this service.

o 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.

o Under those circumstances, documentation must support the severity of pain and functional limitations related to performance of activities of daily living requiring hospitalization.

Treatment Logic

• 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 (Polymethuylmethacrylate) (PMMA).

 

 

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.

 

Percutaneous 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

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD PERCUTANEOUS VERTEBRAL AUGMENTATION (VERTEBRAL AUGMENTATION) (FORMERLY  KYPHOPLASTY)