Notification

Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation


Notification Issue Date: 10/16/2018

This version of the policy will become effective on 01/14/2019.

Definitions of spinal osteotomy and corpectomy procedures were added to the description section.



Medicare Advantage Policy

Title:Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation
Policy #:MA11.024d

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

Percutaneous vertebroplasty (PV or PVP) is considered medically necessary and, therefore, covered when any of the following indications are met:
  • Osteolytic vertebral metastasis and myeloma with severe back pain related to a destruction of the vertebral body, not involving the major part of the cortical bone.
  • Vertebral hemangiomas with aggressive clinical signs (severe pain or nervous compression) and/or aggressive radiological signs.
  • Osteoporotic vertebral collapse with persistent debilitating pain that has not responded to accepted standard medical treatment. Documentation should be available to support the use of PV or PVA early in the treatment regimen.
  • Painful vertebral eosinophilic granuloma with spinal instability.
  • Steroid-induced vertebral fractures.

Percutaneous vertebral augmentation (PVA) (i.e., balloon-assisted percutaneous vertebroplasty or kyphoplasty), is considered medically necessary and, therefore, covered when either of the following indications are met:
  • Osteolytic vertebral metastasis and myeloma with severe back pain related to destruction of the vertebral body, not involving the major part of the cortical bone; or,
  • Osteoporotic vertebral collapse with persistent debilitating pain that has not responded to accepted standard medical treatment. Documentation should be available to support the use of PV or PVA early in the treatment regimen.

EXPERIMENTAL/INVESTIGATIONAL

PV and PVA are considered experimental/investigational and, therefore, not covered for all other indications, including, but not limited to, the following indications:
  • Treatment of lesions involving the sacrum or coccyx
  • Prophylactic for osteoporosis of the spine or for chronic back pain of long-standing duration, even if associated with old compression fractures

ABSOLUTE CONTRAINDICATIONS
PV and PVA are considered not medically necessary and, therefore, not covered for individuals with any of the following absolute contraindications:
  • Absence of a confirmed acute or subacute fracture
  • Symptoms that cannot be related to a fracture
  • Radicular symptoms that are explained by bone impinging on nerves or another anatomic lesion
  • Unstable fracture
  • Asymptomatic vertebral compression fracture
  • Active osteomyelitis, whether fungal, bacterial, or mycobacterial
  • Burst fracture with retropulsed fragments demonstrated by imaging study
  • Uncorrected coagulation disorders
  • Known allergy to any of the materials used in either procedure

In addition, PVA is considered not medically necessary and, therefore, not covered for individuals with the following absolute contraindication:
  • Compression fractures shown by the medical record to be more than one year old

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, vertebroplasty and percutaneous vertebral augmentation are covered under the medical benefits of the Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary and experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

Percutaneous vertebroplasty (also known as PV or PVP) is a therapeutic, interventional radiologic procedure that consists of the injection of a material (usually polymethylmethacrylate) under imaging guidance (either fluoroscopy or CT) into a cervical, thoracic, or lumbar vertebral body lesion for the relief of pain and the strengthening of bone.

Percutaneous vertebral augmentation (also known as balloon-assisted percutaneous vertebroplasty, kyphoplasty, or PVA) is similar to percutaneous vertebroplasty in that stabilization of the collapsed vertebra is accomplished by the injection of methylmethacrylate cement into the body of the vertebra. The primary difference in the case of percutaneous vertebral augmentation is that the fracture itself is at least partially reduced by expanding the intrabody space by the use of inflatable bone tamps, or other device, that displace, remove, or compact bone to create a space, void, or cavity. Once the compression is reduced to an acceptable degree, the bone cement is then injected. In this way, some of the bony deformity and resulting kyphosis may be reduced, often significantly improving the individual’s pain.

Spinal osteotomy procedures are reported when a portion or portions of the vertebral segment or segments is (are) cut and removed in preparation for realigning the spine as part of a spinal deformity correction. These procedures may be required for congenital, developmental, and degenerative spinal deformities.

Corpectomy typically reflects a longitudinal resection of the vertebral body from disc space to disc space often resulting in a destabilization of the complex. In the cervical spine, at least 50% of the vertebral body is removed and in the thoracic/lumbar spine, at least 30% of the corpus is removed.
References

Novitas Solutions, Inc. Local Coverage Determination (LCD) for Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous (L35130). 10/01/2015. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35130&ver=27&Date=10%2f01%2f2015&DocID=L35130&bc=iAAAAAgAAAAAAA%3d%3d&. Accessed October 12th, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

22510, 22511, 22512, 22513, 22514, 22515

EXPERIMENTAL/INVESTIGATIONAL
0200T, 0201T



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medical necessity as listed in the policy.


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation
Description: ICD-10 diagnosis codes







Policy History

Revisions for MA11.024d:
01/14/2019This version of the policy will become effective on 01/14/2019.

Definitions of spinal osteotomy and corpectomy procedures were added to the description section.

Revisions from MA11.024c:
01/02/2018This version of the policy will become effective on 01/02/2018.

The policy has been reviewed to communicate the Company’s continuing position on Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation.

An attachment to this policy with the list of ICD-10 codes was removed.

Revisions from MA11.024b:
08/03/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation.
01/01/2016Revised policy number MA11.024b was issued as a result of a coding update. The following codes were deleted by the AMA, and therefore, deleted from the policy.

S2360 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; cervical

S2361 Each additional cervical vertebral body (List separately in addition to code for primary procedure)

CPT codes exist that represent the services and are already included in the policy.

Revisions from MA11.024a:
10/02/2015This policy version will become effective 10/02/2015.

Revised policy MA11.024a has been updated with ICD-10 coding.

Revisions from MA11.024:
01/01/2015This is a new policy.

Due to a 01/01/2015 code update, the following CPT codes have been deleted: 22520, 22521, 22522, 22523, 22524, 22525, 72291, and 72292. CPT codes 22510, 22511, 22512, 22513, 22514, 22515 have been added by the AMA. The narratives for CPT codes 0200T and 0201T have been revised.





Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A