Notification

Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty


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.



Medical Policy Bulletin


Title:Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty

Policy #:11.14.10q

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

PERCUTANEOUS VERTEBROPLASTY AND KYPHOPLASTY

MEDICALLY NECESSARY
Percutaneous vertebroplasty and kyphoplasty are considered medically necessary and, therefore, covered for any of the following conditions:
  • When used for the treatment of symptomatic osteoporotic vertebral fractures that have failed to respond to conservative treatment (e.g., analgesics, physical therapy, and rest) for at least 6 weeks
  • When used for the treatment of severe pain caused by osteolytic lesions of the spine relating to multiple myeloma or metastatic malignancies

EXPERIMENTAL/INVESTIGATIONAL
Percutaneous vertebroplasty and kyphoplasty for all other indications, including but not limited to their use in acute vertebral fractures due to osteoporosis or trauma, are considered experimental/investigational and, therefore, not covered, because the safety and/or effectiveness of PVP and PKP for such indications cannot be established by review of the available published peer-reviewed literature.

PERCUTANEOUS SACROPLASTY

Percutaneous sacroplasty for all indications, including but not limited to, use in sacral insufficiency fractures due to osteoporosis and spinal lesions due to metastatic malignancies or multiple myeloma, is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, percutaneous vertebroplasty and kyphoplasty are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Subject to the terms and conditions of the applicable benefit contract, percutaneous sacroplasty is not eligible for payment under the medical benefits of the Company’s products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous bone cement devices approved by the FDA for the fixation of pathological fractures of the vertebral body using vertebroplasty or kyphoplasty procedures.

The FDA has issued "Public Health Web Notification: Complications Related to the Use of Bone Cement in Vertebroplasty and Kyphoplasty Procedures." The notification is to encourage facilities and users to report adverse events related to bone cement malfunctions either directly to the manufacturers or to MedWatch, the FDA's voluntary reporting program.

Description

PERCUTANEOUS VERTEBROPLASTY AND KYPHOPLASTY

Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are both performed using interventional radiology, which uses fluoroscopic guidance to inject polymethylmethacrylate (PMMA), a bone cement, through a needle into a weakened vertebral body. These techniques have been proposed as an option to provide mechanical support and symptomatic relief in individuals with osteoporotic vertebral compression fractures (VCFs) or in those with osteolytic lesions of the spine (e.g., multiple myeloma, metastatic malignancies). PVP has also been investigated as an adjunct to surgery for aggressive vertebral body hemangiomas and as a technique to limit blood loss related to surgery. PKP is a variant of vertebroplasty that utilizes a specialized bone tamp, a device used to reduce fractures, with an inflatable balloon. The role of the inflatable balloon is to expand the collapsed vertebral body to its natural height, before injection of the PMMA.

Radiofrequency kyphoplasty is a modification of PKP in which an ultra-high viscosity cement is injected into the fractured vertebral body and radiofrequency is used to achieve the desired consistency of the cement. This cement is designed to restore height and alignment to the fractured vertebra. Kiva® is another mechanical vertebral augmentation technique that utilizes an implant for structural support of the vertebral body and provides a reservoir for bone cement. The Kiva® VCF system consists of a shaped memory coil, which is inserted into the vertebral body over a removable guide wire and is reconfigured into a stack of loops within the vertebral body. The PEEK-OPTIMA® biocompatible polymer implant is then deployed over the coil, which is retracted so that PMMA may be injected through the lumen of the implant. The proposed advantage of the Kiva® system is reduced cement leakage.

Initially, the use of bone cement in PVP or PKP was considered off-label. Several companies have since received US Food and Drug Administration (FDA) approval for use of their bone cement in treating pathological fractures of the vertebral body through these techniques. In July 2004, KyphX HV-RTM bone cement was given 510(k) clearance by the FDA for treatment of pathological fractures of the vertebral body caused by osteoporosis, cancer, or benign lesions using a balloon kyphoplasty. In 2005, Spine-Fix Biomimetic Bone cement and Osteopal V were both issued 510(k) clearance for fixation of pathological fractures of the vertebral body using vertebroplasty or kyphoplasty. The FDA still encourages reporting of all adverse effects of bone cement; leakage of the cement outside the body is a common occurrence and has been reported in 19% to 72% of cases.

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.


PEER-REVIEWED LITERATURE
Percutaneous Vertebroplasty

In a prospective study, Layton et al. (2007) evaluated the safety and effectiveness of PMMA vertebroplasty for the treatment of pain and disability associated with VCFs. All 552 study participants underwent 673 sessions to treat 1000 spinal compression fractures, regardless of the underlying pathologic cause, and were followed for up to 2 years. Outcome measurements included pain response (subjective and visual analog scale [VAS] pain score), change in mobility, change in pain medication usage, and a disability questionnaire. There were improvements in all of the evaluated parameters following PVP and clinically significant complications were encountered in only 1.8% of the treated individuals (n=12). Rib fractures related to lying prone on the fluoroscopy table were the most common complication encountered (n=7). The authors concluded that PVP for the treatment of painful spinal compression fractures resulted in high success rates and low complication rates. The study is limited in its lack of a comparative control group.

In a multicenter, randomized, double-blind, placebo-controlled trial, Buchbinder et al. (2009) evaluated the safety and effectiveness of PVP in individuals with one or two painful osteoporotic VCFs. A total of 78 participants were randomized to undergo PVP (n=38) or a sham procedure (n=40). Ultimately, 91% of individuals (n=71) completed the 6-month follow-up. The primary outcome measurement was a VAS pain score assessed at 1 week and at 1, 3, and 6 months. There were statistically significant reductions in overall pain in both the PVP and sham groups. Similar improvements were seen in both groups with respect to pain at night and at rest, physical functioning, quality of life (QOL), and perceived improvement. Seven incident VCFs (3 in the PVP group and 4 in the sham group) occurred during the 6-month follow-up. The authors concluded that there was no beneficial effect of PVP when compared to a sham procedure in individuals with painful osteoporotic VCFs. The study is limited in its relatively small sample size and short-term follow-up period. The authors also admit that selection bias cannot be ruled out since 30% of potentially eligible participants declined to participate in the study.

In a meta-analysis, Staples et al. (2011) evaluated whether PVP was more effective than placebo for individuals with at least 6 weeks of recently onset pain or with severe pain (i.e., score of at least 8 on a 0 to 10 VAS). The authors combined individual patient level data from two multi-centered randomized controlled trials. A total of 209 individuals (Australian trial, n=78; US trial, n=131) with at least one radiographically confirmed VCF were randomized to PVP or placebo. Twenty-seven percent of individuals (n=57) had recently onset pain and 47% of individuals (n=99) had severe pain at baseline. Outcome measurements included VAS pain scores and function based on a disability questionnaire at 1-month follow-up. For individuals with recently onset pain or with severe pain, there was no statistically significant difference in pain and disability scores. The authors concluded that individual patient data meta-analysis failed to show the effectiveness of PVP when compared to placebo for individuals with recently onset or severe pain. The study is limited in its short-term follow-up and the potential heterogeneity of the patient population.

In a prospective randomized controlled trial, Farrokhi et al. (2011) evaluated the safety and effectiveness of PVP when compared to medical management for the control of pain and improvement of QOL in individuals with osteoporotic VCFs. A total of 105 individuals with acute osteoporotic VCFs were enrolled in the trial and ultimately, 82 were eligible for participation. These individuals were randomized to a PVP group (n=40) or a medical management group (n=42). Primary outcomes included control of pain and improvement in QOL and were measured before treatment and up to 36 months after treatment. There were statistically significant improvements in pain and QOL in the PVP group when compared to the medical management group at up to 24-month follow-up, with improved vertebral body height maintained over 36 months. The incidence of new fractures was statistically significantly higher in the medical management group when compared to the PVP group as well (13.3% vs. 2.2%; p < 0.01). The authors concluded that PVP offered statistically significant improvements in pain and QOL with fewer adjacent-level fractures when compared to medical management.

In a systematic review, Chew et al. (2011) evaluated the safety and effectiveness of PVP for the treatment of spinal metastases and myeloma. Thirty relevant studies were identified, representing 987 individuals aged between 45 and 72 years of age. Five deaths were attributable to PVP, with an additional 19 individuals suffering serious complications related to the procedure. The authors concluded that there was some evidence to suggest that the complication rate may be related to higher cement volume use and that pain reduction ranged between 47 and 87%. They indicated that further research may be needed for this patient population.

In a randomized placebo-controlled trial, Kroon et al. (2014) evaluated the safety and effectiveness of PVP for the treatment of acute osteoporotic vertebral fractures up to 6 months at 24-month follow-up. Eligible participants (n=78) were randomly assigned to receive either PVP (n=38) or a sham procedure (n=40). The primary outcome measurement was overall pain measured on a scale from 0 to 10 on increasing pain. Secondary outcome measurements included pain at rest and at night, disability, QOL, perceived recovery, and adverse events. At 24 months, complete data was available for 73% of participants (n=57). There was no statistically significant difference observed between the PVP and sham groups. The authors concluded that this provided further evidence that the use of PVP in routine care was unsupported.

Percutaneous Kyphoplasty

In a prospective randomized controlled trial, Wardlaw et al. (2009) evaluated the safety and effectiveness of PKP for the treatment of painful VCFs. A total of 300 individuals were randomized to a PKP group (n=149) or a non-surgical care group (n=151). The primary outcome measurement was the difference in change from baseline to 1 month in a physical component summary (PCS) score (scale 0 to 100) between both groups. QOL and other efficacy measurements and safety were assessed up to 12 months. Ultimately, 138 participants in the PKP group and 128 participants in the non-surgical care group completed follow-up at 1 month. Mean PCS score improved for both groups, with a statistically significant greater increase for individuals in the PKP group when compared to the non-surgical care group (7.2 vs. 2.0; p < 0.0001). The frequency of adverse events did not differ between the groups. The authors concluded that PKP was a safe and effective procedure for treating individuals with acute VCFs. The study is limited in its short-term follow-up period.

In a longer-term follow-up of the Wardlaw et al. (2009) study, Boonen et al. (2011) evaluated the safety and effectiveness of PKP for the treatment of acute VCFs at 24-month follow-up. Individuals in the PKP treatment group maintained a statistically significantly greater PCS score improvement when compared to the non-surgical treatment group at 24-month follow-up. There were two device-related serious adverse events in the second year that occurred at the index vertebrae (spondylitis and an anterior cement migration). There was no statistically significant difference between groups in the number of patients with new radiographic VCFs. However, there were fewer VCFs that occurred within the second year (18%). The authors concluded that PKP rapidly reduced pain and improved function, disability, and QOL without increasing the risk of additional VCFs.

In a multicenter, randomized controlled trial, Berenson et al. (2011) evaluated the safety and effectiveness of PKP for individuals with cancer who have painful VCFs (the Cancer Patient Fracture Evaluate [CAFE] study). A total of 134 individuals with 1 to 3 painful VCFs were randomized to a PKP (n=70) or non-surgical control group (n=64). Of these study participants, 65 in the PKP group and 52 in the control group completed 1-month follow-up. Outcome measurements included back-specific functional status measured by a Roland-Morris disability questionnaire (RDQ). The mean RDQ score in the PKP group statistically significantly improved from 17.6 at baseline to 9.1 at 1 month (p < 0.0001). At 1-month follow-up, the PKP effect for RDQ was maintained. There was no statistically significant improvement for the control group. The most common adverse events within the first month for the PKP group were back pain (n=4) and symptomatic VCFs (n=2). There was no statistically significant difference compared to the control group. The authors concluded that for painful VCFs in individuals with cancer, PKP was a safe and effective treatment to rapidly reduce pain and improve function. The study is limited in its short-term follow-up period.

In an industry-funded retrospective cohort study, Edidin et al. (2011) evaluated the mortality risk for individuals with VCF undergoing non-surgical conservative treatment, PKP, or PVP. Using a U.S. Medicare dataset from 2005 to 2008, survival rates were estimated by the Kaplan-Meier method and differences in mortality rates at up to 4 years were assessed by Cox regression, with adjustment for comorbidities. A total of 858,978 individuals with VCF were identified, including 119,253 individuals in the PKP group and 63,693 in the PVP group. At up to 4 years of follow-up, individuals in the surgical cohort (PKP and PVP) had a statistically significantly higher adjusted survival rate of 60.8% compared with 50% of individuals in the non-operated cohort (p < 0.001). The adjusted survival rates following PVP or PKP were 57.3% and 62.8%, respectively (p < 0.001). The relative risk of mortality for individuals in the PKP group was 23% lower than that for the PVP group (p < 0.001). The study is limited in its retrospective nature and the potential for selection bias.

In a comparative effectiveness review, Schroeder et al. (2011) compared PVP and PKP for the treatment of fractures caused by spinal tumors. The authors noted that the literature primarily consisted of case series with only two studies comparing PVP and PKP. Pain scores in both treatment groups were statistically significantly decreased relative to preoperative scores and appeared to have been sustained at up to 1-year follow-up. However, it was unclear whether one treatment provided superior pain relief than the other. Both studies reported decreased analgesic use after both treatments, but neither study compared use between the treatment groups. The authors concluded that there was limited evidence comparing the benefits of PKP and PVP. However, both appeared to be effective in reducing pain with relatively few complications.

In a retrospective comparative study, Otten et al. (2013) evaluated the safety and effectiveness of Kiva® and PKP for the treatment of VCFs. Fifty-two individuals with 68 fractures underwent either Kiva® (n=26) or PKP (n=26). Outcome measurements included VAS pain scores and ODI. The operative time and cement extravasation was also recorded. Radiographs were evaluated for new fractures and vertebral heights. Mean VAS scores improved from baseline in both groups, though at 6-month follow-up the Kiva® had a statistically significant improvement compared to PKP (p < 0.0001). Mean ODI also improved in both groups, though there was no statistically significant difference between the two groups. In the Kiva® group, 2 cases of nonadjacent fractures and one case of adjacent fracture were recorded. In the PKP group, 9 cases of adjacent as well as 5 cases of nonadjacent fractures were observed, representing a statistically significantly higher fracture rate than Kiva®. The authors concluded that Kiva® appeared to be a safe and effective procedure for the treatment of VCFs. The study is limited in its small sample size and retrospective study design.

In a prospective, parallel-group, randomized controlled trial, Korovessis et al. (2013) compared the safety and effectiveness of Kiva® and balloon PKP for the augmentation of fresh osteoporotic VCFs. From a total of 190 individuals with osteoporotic fractures, 10 were excluded. Eighty-two individuals with 133 fractures received Kiva® and 86 individuals with 122 fractures were reinforced with PKP. Outcome measurements included anterior, midline, and posterior vertebral height ratios and Gardner segmental vertebral wedge deformity preoperatively and postoperatively. New fractures were recorded at final observation. All participants were followed for an average of 14 months [13 to 15]. Both Kiva® and PKP significantly restored vertebral height ratios. However, only Kiva® had a statistically significant reduction of the Gardner angle (p = 0.002). The new fracture rate was similar between both groups. Back pain VAS scores and ODI were statistically significantly improved for both groups. The authors concluded that both Kiva® and PKP restored vertebral body height in the short-term, but only Kiva® restored vertebral body wedge deformity. Kiva® was also noted to have significantly lower extracanal leakage than PKP. The authors did admit that longer observation was needed to determine whether these radiological changes have any functional impact. The study is limited in its relatively short-term follow-up period.

In a separate study to evaluate individuals with osteolytic vertebral body metastasis, Korovessis et al. (2014) compared the cement leakage rate and efficacy for vertebral body restoration of PKP and Kiva®. Twenty-three individuals with 41 osteolytic vertebral bodies received Kiva® and 24 individuals with 43 osteolytic vertebral bodies were reinforced with PKP. All osteolyses were graded as Tomita 1 to 3. Vertebral body height ratios, Gardner kyphotic deformity, and PMMA leakage were measured. VAS pain scores and ODI were assessed for functional outcome measurement. No participants survived after 3 months. Asymptomatic PMMA leakage occurred in 9.3% of the vertebrae in the PKP group (n=4). Vertebral body height ratios and Gardner angles did not have a statistically significant improvement in both groups. VAS and ODI did have a statistically significant improvement in both groups. The authors concluded that PKP and Kiva® provided significant spinal pain relief in individuals with osteolytic metastasis. The study is limited in its small sample size.

In a multi-center, randomized controlled trial (i.e., Kivas Safety and Effectiveness Trial; KAST), Tutton et al. (2015) evaluated the safety and effectiveness of the Kiva® system to standard balloon PKP for the treatment of individuals with painful, osteoporotic VCFs. The objective was to demonstrate noninferiority. Three hundred individuals with 1 or 2 painful osteoporotic VCFs were randomized to receive either Kiva® (n=153) or PKP (n=147) and were followed for 12 months. The primary outcome measurement was a composite at 12 months defined as a reduction in fracture pain by at least 15 mm on the VAS pain score, maintenance of improvement on the Oswestry Disability Index (ODI), and the absence of device-related serious adverse events. Secondary outcome measurements included cement usage, extravasation, and adjacent level fracture. A mean improvement of 70.8 and 71.8 point in the VAS pain score and 38.1 and 42.2 points in the ODI was noted in Kiva® and PKP, respectively. No device-related serious adverse events occurred. The authors noted that the primary outcome demonstrated noninferiority of Kiva® to PKP. The secondary outcome measurements demonstrated superiority with respect to cement use and site-reported extravasation, with a positive trend in adjacent level fractures that warranted further study. The authors concluded that the Kiva® system was noninferior to PKP. The study is limited in its relatively short-term follow-up period and significant differences in risk factors between the two groups at baseline.

In a systematic review and meta-analysis, Gu et al. (2015) compared the outcomes of PVP and PKP for the treatment of osteoporotic VCFs. Twenty-nine studies, including prospective randomized, non-randomized, and retrospective comparative studies, were evaluated, representing 2,838 individuals (1,384 PKP; 1,454 PVP). No statistically significant differences were found in mean pain scores between the two groups postoperatively (p = 0.39) or at 12-month follow-up (p = 0.64). No statistically significant differences were found in disability postoperatively (p = 0.74) or at 12 months (p = 0.70). PKP was associated with lower odds of new fracture, though not statistically significant (p = 0.06). PKP did have a statistically significantly lower odds of extraosseous cement leakage (p < 0.01) and a greater reduction in kyphotic angle (p < 0.01). The authors concluded that there was no significant difference found between PKP and PVP in short- and long-term pain and disability outcomes. However, further studies were needed to better determine if any particular subgroups of individuals would benefit more from PVP or PKP for the treatment of osteoporotic VCFs. The study is limited in its heterogeneous design.

PERCUTANEOUS SACROPLASTY

Percutaneous sacroplasty emerged from the treatment of insufficiency fractures in the thoracic and lumbar vertebrae with vertebroplasty. The procedure, which is equivalent to vertebroplasty, is a guided injection of PMMA into the sacral region. While first described in 2001 as a treatment for symptomatic sacral metastatic lesions, sacroplasty is a minimally invasive procedure used as an alternative to conservative management of sacral insufficiency fractures (SIFs). SIFs are the result of excessive stress of weakened bone and also often the cause of low back pain among the elderly. Osteoporosis is the most common risk factor for SIF.

The use of PMMA in sacroplasty is considered an off-label use in regulated bone cements (such as Spine-FIX® Biomimetic Bone Cement and Osteopal® V). The 510(k) marketing clearance was for the fixation of pathological fractures of the vertebral body using vertebroplasty or kyphoplasty procedures. Sacroplasty was not included in the labeling.

PEER-REVIEWED LITERATURE
In a multicenter, prospective observational study, Frey et al. (2008) evaluated the outcomes and complication rates associated with sacroplasty for the treatment of SIFs in individuals with low back pain. Fifty-two consecutive individuals with symptomatic SIFs were evaluated for 12 months and outcome measurements included analgesic usage and patient satisfaction. Baseline VAS, analgesic usage, and duration of symptoms were recorded. The mean age of the patient population was 75.9 years with a mean symptom duration of 34.5 days. The mean VAS score at baseline was 8.1. Thirty minutes after the procedure, the mean VAS score was 3.4 and at 52-week follow-up was 0.8, representing a statistically significant difference. One case of transient S1 radiculitis occurred, but eventually resolved with a transforaminal epidural steroid injection. The authors concluded that sacroplasty for individuals with SIF appeared to be associated with rapid and sustained pain relief. They called for more rigorous trials to be conducted to provide definitive evidence regarding the safety and effectiveness of sacroplasty for SIFs. The study is limited in its relatively small sample size, short-term follow-up period, and lack of a comparative control group.

In a retrospective study, Kortman et al. (2013) assessed the outcomes and safety associated with CT-guided percutaneous sacroplasty in individuals with SIFs or pathologic sacral lesions. Two hundred and forty-three individuals were included in the study; 204 with painful SIFs and 39 with symptomatic sacral lesions. Outcome measurements included hospitalization status, pre- and post-treatment VAS scores, analgesic use, and complications. Individuals were followed for at least 1 year after their sacroplasty procedure. Among individuals with painful SIFs, the mean VAS score statistically significantly improved from 9.2 ± 1.1 to 1.9 ± 1.7 (p < 0.001). Among individuals with sacral lesions, the mean VAS score statistically significantly improved from 9.0 ± 0.9 to 2.6 ± 2.4 (p < 0.001). One individual who was treated for SIF experienced radicular pain due to local cement extravasation required surgical decompression for symptomatic relief. The authors concluded that CT-guided percutaneous sacroplasty was a safe and effective procedure for the treatment of painful SIFs or sacral lesions. The study is limited in its heterogeneous study population, retrospective study design, and lack of a comparative control group.

In a retrospective study, Pereira et al. (2013) assessed the outcomes and safety associated with percutaneous sacroplasty in individuals with tumors or SIFs. Fifty-eight consecutive individuals underwent 67 sacroplasty procedures for intractable pain from sacral tumors (84.5%) or from osteoporotic fractures (15.5%) and were followed for 1 month. Outcome measurements included VAS scores, patient satisfaction, and complication rates. The mean VAS score was 5.3 ± 2.0 pre-procedure and 1.7 ± 1.8 post-procedure. At 1-month follow-up, 58.5% of individuals (n=34) experienced a mild improvement, 26% of individuals (n=15) had a significant improvement, while 15.5% of individuals (n=9) had unchanged or worse pain. Decreased analgesic consumption was observed in 34% of individuals (n=20) after the procedure. There were major complications in two of the study participants. The authors concluded that percutaneous sacroplasty was a safe and effective technique for metastatic and osteoporotic fractures. The study is limited in its relatively small sample size, heterogeneous study population, short-term follow-up period, retrospective study design, and lack of a comparative control group.

In a retrospective study, Dougherty et al. (2014) evaluated the safety and effectiveness of percutaneous sacroplasty in 57 individuals with SIFs. An 11-point numerical pain rating score was recorded at rest and at activity pre- and post-procedure. Median post-procedure follow-up time was 2.5 weeks among the 79% of participants (n=45) who were ultimately followed. Eighty-two percent (n=37) experienced a numerical or descriptive decrease from initial pain at follow-up. Median rest pain scores collected from 29 participants decreased from 7 to 2, representing a statistically significant decrease. Seventy-six percent of these participants (n=22) had at least a 30% decrease in rest pain scores. The authors concluded that percutaneous sacroplasty was a safe and effective treatment in individuals with painful osteoporotic SIFs. The study is limited in its relatively small sample size, short-term follow-up period, retrospective study design, lack of a comparative control group, and heterogeneous analysis.

SUMMARY

PERCUTANEOUS VERTEBROPLASTY AND KYPHOPLASTY
In 2003, the National Institute for Clinical Excellence (NICE) published guidelines on PVP. NICE concluded that the current evidence on the safety and effectiveness of PVP for VCFs appeared adequate to support the use of the procedure in individuals with severe painful osteoporosis with loss of height and/or compression fractures of the vertebral body. NICE recommended that the procedure be limited to individuals with refractory pain. In 2006, NICE published guidelines on balloon kyphoplasty for VCFs. The guidelines stated that the current evidence on the safety and effectiveness of PKP appeared adequate to support its use. In 2008, NICE recommended PVP for individuals with vertebral metastases and those with no evidence of metastatic spinal cord compression or spinal instability provided they have mechanical pain refractory to conservative management (e.g., analgesics). In 2013, NICE published guidelines for the treatment of osteoporotic vertebral compression fractures, recommending that PVP and PKP be considered as options in individuals who have severe, ongoing pain after a recent, unhealed vertebral fracture, despite optimal pain management, and in individuals whose pain has been confirmed to be at the level of the fracture by physical examination and imaging.

In 2010, the American College of Radiology (ACR) published guidelines on the management of VCFs. The guidelines stated that conservative management was the first-line and gold standard treatment of painful VCFs. However, in individuals with refractory pain, PVP and PKP may be indicated. In a 2013 update to their guidelines, ACR notes that most VCFs are resolved within 4 to 6 weeks with the more conservative first-line treatment including the use of nonsteroidal anti-inflammatory drugs. Conservative treatment failure was defined as pain refractory to oral medications over 6 to 12 weeks.

In 2010, the American Academy of Orthopaedic Surgeons (AAOS) published a clinical practice guideline on the treatment of osteoporotic spinal compression fractures. Based on a literature review through September 2009, the AAOS strongly recommended against the use of PVP in individuals with an osteoporotic spinal compression fracture who are neurologically intact. The AAOS did provide a weak recommendation in support of PKP for individuals who present with an osteoporotic spinal compression fracture.

In 2012, a joint practice guideline from the ACR, the American Society of Neuroradiology (ASN), the American Society of Spine Radiology (ASSR), the Society of Interventional Radiology (SIR), and the Society of Neurointerventional Surgery (SNIS) addressed PVP and PKP. These procedures were considered to be safe and established for select patient populations. In a 2014 position statement, they noted that percutaneous vertebral augmentation, using either PVP or PKP, was a safe, effective, and durable procedure in appropriate individuals with symptomatic osteoporotic and neoplastic fractures. They also noted that these procedures should be offered only when nonoperative medical therapy has not provided adequate relief or when pain is significantly altering the individual's quality of life.

PVP and PKP have been used to treat individuals with osteoporotic VCFs for osteolytic lesions of the spine (i.e., multiple myeloma or metastatic malignancies). There exist prospective randomized trials that indicate that PVP and PKP may alleviate pain and improve function in individuals who have failed to respond to conservative treatment (i.e., at least 6 weeks of analgesics, physical therapy, and rest). This is based on the decreased use of analgesics and improvements in physical function after PVP or PKP were performed. Use of PVP and PKP for treatment of vertebral hemangiomas has also been investigated. Studies suggest that use of PVP or PKP on vertebral hemangiomas for treatment of the vertebral body component of the vascular lesion may prevent substantial blood loss, which is common during a primary surgical resection.

Based on the available published peer-reviewed literature, clinical input, and guidelines from relevant medical societies, the current scientific evidence appears to support the use of PVP or PKP for the treatment of symptomatic osteoporotic VCFs refractory to conservative treatment and caused by osteolytic lesions of the spine relating to multiple myeloma or metastatic malignancies.

PERCUTANEOUS SACROPLASTY
Based on the available published peer-reviewed literature, clinical input, and lack of guidelines from relevant medical societies, the current scientific evidence is insufficient to permit conclusions regarding the safety and effectiveness of sacroplasty. The majority of the available literature consists of case series and do not compare sacroplasty to conventional management. Randomized controlled trials with appropriate follow-up and valid comparative control groups are necessary to determine the safety, effectiveness, and long-term outcomes of sacroplasty.
References


ACR-ASNR-ASSR-SIR-SNIS. Practice parameter for the performance of vertebral augmentation 2014; Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Vertebral_Augmentation.pdf. Accessed November 01, 2017.

Alvarez L, Alcaraz M, Perez-Higueras A, et al. Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures. Spine. 2006;31(10):1113-8.

Alvarez L, Perez-Higueras A, Granizo JJ, et al. Predictors of outcomes of percutaneous vertebroplasty for osteoporotic vertebral fractures. Spine. 2005;30(1):87-92.

Alvarez L, Perez-Higueras A, Quinones D, et al. Vertebroplasty in the treatment of vertebral tumors: postprocedural outcome and quality of life. Eur Spine J. 2003;12(4):356-60.

American Academy of Orthopaedic Surgeons (AAOS). Treating spinal compression fractures. 2010; Available at: http://www.aaos.org/news/aaosnow/oct10/cover1.asp. Accessed November 01, 2017.

Aretxabala I, Fraiz E, Perez-Ruiz F, et al. Sacral insufficiency fractures. High association with pubic rami fractures. Clin Rheumatol. 2000;19(5):399-401.

Baerlocher MO, Saad WE, Dariushnia, S et al. Quality improvement guidelines for percutaneous vertebroplasty. J Vasc Interv Radiol. 2014 25(2):165-70.

Barr JD, Jensen ME, Hirsch JA, et al. Position statement on percutaneous vertebral augmentation: a consensus statement developed by the Society of Interventional Radiology (SIR), American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), American College of Radiology (ACR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), Canadian Interventional Radiology Association (CIRA), and the Society of NeuroInterventional Surgery (SNIS). J Vasc Interv Radiol. 2014;25(2):171-81.

Berlemann U, Franz T, Orler R, et al. Kyphoplasty for treatment of osteoporotic vertebral fractures: a prospective non-randomized study. Eur Spine J. 2004;13(6):496-501.

Berenson J, Pflugmacher R, Jarzem P, et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol. 2011;12(3):225-35.

Binaghi S, Guntern D, Schnyder P, et al. A new, easy, fast, and safe method for CT-guided sacroplasty. Eur Radiol. 2006;16(12):2875-8.

Blue Cross Blue Shield Association Technology Evaluation Center (TEC). Percutaneous kyphoplasty for vertebral fractures caused by osteoporosis and malignancy. TEC Assessments. 2004; Volume 19, Tab 12.

Blue Cross Blue Shield Association Technology Evaluation Center (TEC). Percutaneous kyphoplasty for vertebral fractures caused by osteoporosis or malignancy. TEC Assessments. 2005; Volume 20, Tab 7.

Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Percutaneous Vertebroplasty. TEC Assessments 2000; Volume 15, Tab 21.

Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Percutaneous Vertebroplasty for Vertebral Fractures Caused by Osteoporosis, Malignancy, or Hemangioma. TEC Assessments 2004; Volume 19, Tab 13.

Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Percutaneous Vertebroplasty for Vertebral Fractures Caused by Osteoporosis or Malignancy. TEC Assessments 2005; Volume 20, Tab 6.

Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Percutaneous Vertebroplasty or Kyphoplasty for Vertebral Fractures Caused by Osteoporosis. TEC Assessments 2009; Volume 24, Tab 7.

Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Percutaneous Vertebroplasty or Kyphoplasty for Vertebral Fractures Caused by Osteoporosis or Malignancy. TEC Assessments 2008; Volune 23; Tab 5.

Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Percutaneous vertebroplasty for vertebral fractures caused by osteoporosis. TEC Assessments 2010; Volume 25, Tab 9.

Boonen S, Van Meirhaeghe J, Bastian L, et al. Balloon kyphoplasty for the treatment of acute vertebral compression fractures: 2-year results from a randomized trial. J Bone Miner Res. 2011; 26(7):1627-37.

Brook AL, Mirsky DM, Bello JA. Computerized tomography guided sacroplasty: a practical treatment for sacral insufficiency fracture: case report. Spine (Phila Pa 1976). 2005;30(15):E450-4.

Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361(6):557-68.

Butler CL, Given CA, 2nd, Michel SJ, et al. Percutaneous sacroplasty for the treatment of sacral insufficiency fractures. Am J Roentgenol. 2005;184(6):1956-9.

Chang X, Lv YF, Chen B, et al. Vertebroplasty versus kyphoplasty in osteoporotic vertebral compression fracture: a meta-analysis of prospective comparative studies. Int Orthop. 2015;39(3):491-500.

Chen D, An ZQ, Song S, et al. Percutaneous vertebroplasty compared with conservative treatment in patients with chronic painful osteoporotic spinal fractures. J Clin Neurosci. 2014;21(3):473-477.

Chen JF, Lee ST, Lui TN, et al. Percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures: a preliminary report. Chang Gung Med J. 2002;25(5):306-14.

Chen LH, Niu CC, Yu SW, et al. Minimally invasive treatment of osteoporotic vertebral compression fracture. Chang Gung Med J. 2004;27(4):261-7.

Chew C, Craig L, Edwards R, et al. Safety and efficacy of percutaneous vertebroplasty in malignancy: a systematic review. Clin Radiol. 2011;66(1):63-72.

Chow E, Holden L, Danjoux C, et al. Successful salvage using percutaneous vertebroplasty in cancer patients with painful spinal metastases or osteoporotic compression fractures. Radiother Oncol. 2004;70(3):265-7.

Comstock BA, Sitlani CM, Jarvik JG, et al. Investigational vertebroplasty safety and efficacy trial (INVEST): patient-reported outcomes through 1 year. Radiology. 2013;269(1):224-31.

Coumans JV, Reinhardt MK, Lieberman IH. Kyphoplasty for vertebral compression fractures: 1-year clinical outcomes from a prospective study. J Neurosurg Spine. 2003;99(1):44-50.

Crandall D, Slaughter D, Hankins PJ, et al. Acute versus chronic vertebral compression fractures treated with kyphoplasty: early results. Spine J. 2004;4(4):418-24.

Cyteval C, Baron Sarrabere MP, et al. Acute osteoporotic vertebral collapse: open study on percutaneous injection of acrylic surgical cement in 20 patients. Am J Roentgenol. 1999;173(6):1685-90.

Deen HG, Nottmeier EW. Balloon kyphoplasty for treatment of sacral insufficiency fractures. Report of three cases. Neurosurg Focus. 2005;18(3):e7.

Dehdashti AR, Martin JB, Jean B, et al. PMMA cementoplasty in symptomatic metastatic lesions of the S1 vertebral body. Cardiovasc Intervent Radiol. 2000;23(3):235-7.

Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67-81.

Diamond TH, Bryant C, Browne L, et al. Clinical outcomes after acute osteoporotic vertebral fractures: a 2-year non-randomised trial comparing percutaneous vertebroplasty with conservative therapy. Med J Aust. 2006;184(3):113-7.

Diamond TH, Champion B, Clark WA. Management of acute osteoporotic vertebral fractures: a nonrandomized trial comparing percutaneous vertebroplasty with conservative therapy. Am J Med. 2003;114(4):257-65.

Do HM, Kim BS, Marcellus ML, et al. Prospective analysis of clinical outcomes after percutaneous vertebroplasty for painful osteoporotic vertebral body fractures. Am J Neuroradiol. 2005;26(7):1623-8.

Dohm M, Black CM, Dacre A, et al. A randomized trial comparing balloon kyphoplasty and vertebroplasty for vertebral compression fractures due to osteoporosis. AJNR Am J Euroradiol. 2014;35(12):2227-2236.

Doody O, Czarnecki C, Given MF, et al. Vertebroplasty in the management of traumatic burst fractures: a case series. J Med Imaging Radiat Oncol. 2009;53(5):489-92.

Dougherty RW, McDonald JS, Cho YW, et al. Percutaneous sacroplasty using CT guidance for pain palliation in sacral insufficiency fractures. J Neurointerv Surg. 2014;6(1):57-60.

Dudeney S, Lieberman IH, Reinhardt MK, et al. Kyphoplasty in the treatment of osteolytic vertebral compression fractures as a result of multiple myeloma. J Clin Oncol. 2002;20(9):2382-7.

Edidin AA, Ong KL, Lau E, et al. Mortality risk for operated and nonoperated vertebral fracture patients in the medicare population. J Bone Miner Res. 2011; 26(7):1617-26.

Farrokhi MR, Alibai E, Maghami Z. Randomized controlled trial of percutaneous vertebroplasty versus optimal medical management for the relief of pain and disability in acute osteoporotic vertebral compression fractures. J Neurosurg Spine. 2011;14(5):561-569.

Fourney DR, Schomer DF, Nader R, et al. Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients. J Neurosurg Spine. 2003;98(1):21-30.

Frey ME, Depalma MJ, Cifu DX, et al. Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study. Spine J. 2008;8(2):367-73.

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Gerszten PC, Germanwala A, Burton SA, et al. Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures. J Neurosurg Spine. 2005;3(4):296-301.

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Grafe IA, Da Fonseca K, Hillmeier J, et al. Reduction of pain and fracture incidence after kyphoplasty: 1-year outcomes of a prospective controlled trial of patients with primary osteoporosis. Osteoporos Int. 2005;16(12):2005-12.

Gray LA, Jarvik JG, Heagerty PJ, et al. INvestigational Vertebroplasty Efficacy and Safety Trial (INVEST): a randomized controlled trial of percutaneous vertebroplasty. BMC Musculoskelet Disord. 2007;8:126.

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Gu CN, Brinjiki W, Evans AJ, et al. Outcomes of vertebroplasty compared with kyphoplasty: a systematic review and meta-analysis. J Neurointerv Surg. 2016;8(6):636-42.

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Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361(6):569-79.

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Kaufmann TJ, Jensen ME, Schweickert PA, et al. Age of fracture and clinical outcomes of percutaneous vertebroplasty. Am J Neuroradiol. 2001;22(10):1860-3.

Khanna AJ, Reinhardt MK, Togawa D, et al. Functional outcomes of kyphoplasty for the treatment of osteoporotic and osteolytic vertebral compression fractures. Osteoporos Int. 2006;17(6):817-26.

Klazen CA, Lohle PN, de Vries J, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet. 2010;376(9746):1085-92.

Klazen C, Verhaar H, Lampmann L, et al. VERTOS II: Percutaneous vertebroplasty versus conservative therapy in patients with painful osteoporotic vertebral compression fractures; rationale, objectives and design of a multicenter randomized controlled trial. Trials. 2007;8(1):33.

Kobayashi K, Shimoyama K, Nakamura K, et al. Percutaneous vertebroplasty immediately relieves pain of osteoporotic vertebral compression fractures and prevents prolonged immobilization of patients. Eur Radiol. 2005;15(2):360-7.

Komp M, Ruetten S, Godolias G. Minimally invasive therapy for functional unstable osteoporotic vertebral fracture by means of kyphoplasty: a prospective comparative study of 18 surgically and 17 conservatively treatment patients. J Miner Stoffwechs. 2004;11(suppl 1):13-15. (in German; translated)

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Ledlie JT, Renfro MB. Kyphoplasty treatment of vertebral fractures: 2-year outcomes show sustained benefits. Spine. 2006;31(1):57-64.

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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)

C41.2 Malignant neoplasm of vertebral column

C79.51 Secondary malignant neoplasm of bone

C79.52 Secondary malignant neoplasm of bone marrow

C7B.03 Secondary carcinoid tumors of bone

C90.00 Multiple myeloma not having achieved remission

C90.01 Multiple myeloma in remission

C90.02 Multiple myeloma in relapse

M48.50xA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture

M48.50xD Collapsed vertebra, not elsewhere classified, site unspecified, subsequent encounter for fracture with routine healing

M48.50xG Collapsed vertebra, not elsewhere classified, site unspecified, subsequent encounter for fracture with delayed healing

M48.50xS Collapsed vertebra, not elsewhere classified, site unspecified, sequela of fracture

M48.51xA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture

M48.51xD Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, subsequent encounter for fracture with routine healing

M48.51xG Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, subsequent encounter for fracture with delayed healing

M48.51xS Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, sequela of fracture

M48.52xA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture

M48.52xD Collapsed vertebra, not elsewhere classified, cervical region, subsequent encounter for fracture with routine healing

M48.52xG Collapsed vertebra, not elsewhere classified, cervical region, subsequent encounter for fracture with delayed healing

M48.52xS Collapsed vertebra, not elsewhere classified, cervical region, sequela of fracture

M48.53xA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture

M48.53xD Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with routine healing

M48.53xG Collapsed vertebra, not elsewhere classified, cervicothoracic region, subsequent encounter for fracture with delayed healing

M48.53xS Collapsed vertebra, not elsewhere classified, cervicothoracic region, sequela of fracture

M48.54xA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture

M48.54xD Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with routine healing

M48.54xG Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with delayed healing

M48.54xS Collapsed vertebra, not elsewhere classified, thoracic region, sequela of fracture

M48.55xA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture

M48.55xD Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with routine healing

M48.55xG Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with delayed healing

M48.55xS Collapsed vertebra, not elsewhere classified, thoracolumbar region, sequela of fracture

M48.56xA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture

M48.56xD Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture with routine healing

M48.56xG Collapsed vertebra, not elsewhere classified, lumbar region, subsequent encounter for fracture with delayed healing

M48.56xS Collapsed vertebra, not elsewhere classified, lumbar region, sequela of fracture

M48.57xA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture

M48.57xD Collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent encounter for fracture with routine healing

M48.57xG Collapsed vertebra, not elsewhere classified, lumbosacral region, subsequent encounter for fracture with delayed healing

M48.57xS Collapsed vertebra, not elsewhere classified, lumbosacral region, sequela of fracture

M80.08xA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture

M80.08xD Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing

M80.08xG Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing

M80.08xK Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion

M80.08xP Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion

M80.08xS Age-related osteoporosis with current pathological fracture, vertebra(e), sequela

M80.88xA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture

M80.88xD Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing

M80.88xG Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing

M80.88xK Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion

M80.88xP Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion

M80.88xS Other osteoporosis with current pathological fracture, vertebra(e), sequela

M84.48xA Pathological fracture, other site, initial encounter for fracture

M84.48xD Pathological fracture, other site, subsequent encounter for fracture with routine healing

M84.48xG Pathological fracture, other site, subsequent encounter for fracture with delayed healing

M84.48xK Pathological fracture, other site, subsequent encounter for fracture with nonunion

M84.48xP Pathological fracture, other site, subsequent encounter for fracture with malunion

M84.48xS Pathological fracture, other site, sequela

M84.58xA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture

M84.58xD Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with routine healing

M84.58xG Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with delayed healing

M84.58xK Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with nonunion

M84.58xP Pathological fracture in neoplastic disease, other specified site, subsequent encounter for fracture with malunion

M84.58xS Pathological fracture in neoplastic disease, other specified site, sequela

M85.9 Disorder of bone density and structure, unspecified

M89.9 Disorder of bone, unspecified

M94.9 Disorder of cartilage, unspecified



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions for 11.14.10q:
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 11.14.10p:
07/02/2018This version of the policy will become effective on 07/02/2018.

The policy has been reviewed to communicate the Company’s continuing position on Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty.

ICD-10 codes have been added back to this policy bulletin.

Revisions from 11.14.10o:
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, Kyphoplasty, and Sacroplasty.

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


Effective 10/05/2017 this policy has been updated to the new policy template format.


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

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.