LCD/NCD Portal

L29257

 

PERCUTANEOUS VERTEBROPLASTY

 

01/01/2012

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

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

• Painful osteolytic vertebral body metastatic disease.

• Painful multiple myeloma involving the vertebral body.

• Painful and/or aggressive hemangioma.

• Painful, debilitating, osteoporotic vertebral collapse/compression fractures that have not responded to conservative medical treatment 2-4 week period of immobilization such as:

• Restricted activity/bracing.

• Analgesia/scheduled narcotic usage.

• Severe pain and functional debilitation related to activities of daily living due to chronic vertebral collapse/compression fractures that require hospitalization for pain control and treatment.

o Conservative medical management is NOT considered appropriate for such patients.

o 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.

o As well as the patient’s neurological condition, general state of health and life expectancy.

 

• Percutaneous vertebroplasty is CONTRAINDICATED in coagulation disorders due to the large diameter of the needles used for injection.

• Relative contraindications to performance of a percutaneous vertebroplasty are:

o Extensive vertebral destruction, significant vertebral collapse (i.e., vertebra reduced to less than one-third its original height).

o Neurological symptoms related to compression.

o When there is no neurosurgical backup for emergency decompression in the event a neurological deficit develops during the injection of methyl methacrylate.

 

 

CPT/HCPCS Codes

 

22520 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; THORACIC

22521 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR

22522 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; 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

228.09 HEMANGIOMA OF OTHER SITES

238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS

733.13 PATHOLOGICAL FRACTURE OF VERTEBRAE

805.00 CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL

805.01 CLOSED FRACTURE OF FIRST CERVICAL VERTEBRA

805.02 CLOSED FRACTURE OF SECOND CERVICAL VERTEBRA

805.03 CLOSED FRACTURE OF THIRD CERVICAL VERTEBRA

805.04 CLOSED FRACTURE OF FOURTH CERVICAL VERTEBRA

805.05 CLOSED FRACTURE OF FIFTH CERVICAL VERTEBRA

805.06 CLOSED FRACTURE OF SIXTH CERVICAL VERTEBRA

805.07 CLOSED FRACTURE OF SEVENTH CERVICAL VERTEBRA

805.08 CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE

805.10 OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL

805.11 OPEN FRACTURE OF FIRST CERVICAL VERTEBRA

805.12 OPEN FRACTURE OF SECOND CERVICAL VERTEBRA

805.13 OPEN FRACTURE OF THIRD CERVICAL VERTEBRA

805.14 OPEN FRACTURE OF FOURTH CERVICAL VERTEBRA

805.15 OPEN FRACTURE OF FIFTH CERVICAL VERTEBRA

805.16 OPEN FRACTURE OF SIXTH CERVICAL VERTEBRA

805.17 OPEN FRACTURE OF SEVENTH CERVICAL VERTEBRA

805.18 OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE

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

805.3 OPEN FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY

805.4 CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY

805.5 OPEN FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY

805.6 CLOSED FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY

805.7 OPEN FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY

805.8 CLOSED FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY

805.9 OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY

 

 

Documentation Requirements

• Medical record documentation (e.g., office/progress notes, procedure notes) maintained by the provider 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 vertebral collapse/compression fractures, 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 vertebral collapse/compression fractures 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 vertebroplasty is a therapeutic, interventional neurosurgical and radiological procedure that consists of the percutaneous injection of a biomaterial, methyl methacrylate, into a lesion of a cervical, thoracic, or lumbar vertebral body.

• The procedure is utilized for pain relief and bone strengthening of weakened vertebral bodies.

• The procedure is performed under fluoroscopic guidance, although some prefer the use of computed tomography (CT) with fluoroscopy for needle positioning and injection assessment.

• An intraosseous venogram is sometimes performed before cement injection to determine whether the needle is positioned within a direct venous anastomosis to the central or epidural veins, to minimize extravasation into venous structures.

• Conscious sedation with additional local anesthesia (1% lidocaine) is generally utilized; however, patients who experience difficulties with ventilation or are unable to tolerate prone position during the procedure may require general anesthesia or deep sedation with airway and ventilation support.

• The methyl methacrylate is injected into the vertebral body until resistance is met or until cement reaches the posterior wall.

• The procedure usually lasts from 1 to 2 hours, unless cement is injected into two or more vertebral bodies. The patient must remain flat for about three hours following the procedure.

 

 

Sources of Information and Basis for Decision

 

Abeloff, M; Armitage, J; Neiderhuber, J; et al (2004). Clinical Oncology, 3rd edition. p 1122, Elsevier.

 

Diamond, T; Champion, B; William, C (2003). Management of acute osteoporotic vertebral fractures: a nonrandomized trial comparing percutaneous vertebroplasty with conservative therapy. American Journal of Medicine 114 (4).

 

Elliot, D. (2002). Percutaneous Vertebroplasty. Radiology Wise 3(5).

 

Jashvant, P (2005). Percutaneous Vertebroplasty. Retrieved from http://www.emedicine.com/neuro/topic682.htm on June 15, 2005.

 

Levine, S; Perin, L; Hayes; et al (2000). An Evidence-Based evaluation of percutaneous vertebroplasty. Managed Care Magazine, available at http://www.managedcaremag.com/archives/0003/0003.percut.html

 

Predey, T; Sewall, L; Smith, S (2002). Percutaneous Vertebroplasty: New Treatment for Vertebral Compression Fractures. American Family Physician 66(4).

 

Spivak, J (2002). Vertebroplasty: Weighing the benefits and the risks. American Family Physician 66(4).

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD PERCUTANEOUS VERTEBROPLASTY