LCD : Kyphoplasty (L1951)

LCD for Kyphoplasty (L1951)

Contractor Information

Contractor Name ^{back to top}
BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)
Contractor Number ^{back to top}
00390
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back
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L1951

LCD Title ^{back
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Kyphoplasty

Contractor's Determination Number ^{back
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L1951

AMA CPT / ADA CDT Copyright Statement ^{back
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CPT codes, descriptions and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. � 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back
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Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction ^{back
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New Jersey
Tennessee

Secondary Geographic Jurisdiction ^{back
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Alaska
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Oversight Region ^{back
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Region IV

Original Determination Effective Date ^{back
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For services performed on or after 09/29/2002

Original Determination Ending Date ^{back
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Revision Effective Date ^{back
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For services performed on or after 12/09/2005

Revision Ending Date ^{back
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Indications and Limitations of Coverage and/or Medical Necessity ^{back
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Kyphoplasty is a minimally invasive surgical procedure designed to stop pain caused by an osteoporotic fracture of the vertebral body, to stabilize the bone and to restore some or all of the lost vertebral body height due to the compression fracture.

The procedure is performed at a hospital under fluoroscopic guidance and may be done under local or general anesthesia. The physician makes a small incision in the patient�s back and creates a pathway into the fractured bone. An orthopedic balloon is placed through the pathway and inflated. The balloon is then deflated and removed, leaving a space within the vertebra. The space is injected with polymethylmethacrylate (PMMA) to support the bone and prevent further collapse, stabilizing the fracture and providing immediate pain relief in many cases. The inflation of the balloon prior to the injection may partially restore vertebral body height and configuration.

The procedure generally takes about one hour per vertebra involved and must be followed by routine post-operative recovery.

The Least You Need to Know

Kyphoplasty is covered for the treatment of persistent debilitating pain caused by the recent(usually within 10 weeks) pathologic fracture or collapse of thoracic and/or lumbar vertebrae. Conservative treatment must have failed and other causes of pain must be ruled out. It is not covered as a prophylactic procedure for osteoporosis,as a treatment for structural deformity in the absence of pain,or a remedy for non-specific chronic back pain.

Indications

The principal indication for Kyphoplasty is osteoporotic vertebral collapse with persistent debilitating pain that has not responded to accepted standard medical treatment. Patients experiencing painful symptoms with or without spinal deformities from recent (less than 10 weeks) osteoporotic compression fractures are candidates for kyphoplasty. Kyphoplasty should be completed within 8 weeks of the occurrence of the fracture for the highest probability of restoring height. Kyphoplasty may be performed after 10 weeks only if an MRI documents significant residual instability and malleability as evidenced by persistent local edema and lack of new calcification.

Kyphoplasty has been used in fractures that were due to primary osteoporosis, secondary osteoporosis, multiple myeloma, and osteolytic metastatic disease. Performance of a kyphoplasty procedure will be considered medically reasonable and necessary for the following indications:

Painful osteolytic vertebral metastasis;
Multiple myeloma with painful vertebral body involvement
Painful, debilitating osteoporotic vertebral collapse/compression fractures that have not responded to two to four weeks of appropriate conservative medical treatment (e.g., a period of immobilization such as restricted activity/bracing and analgesia/scheduled narcotic).

Limitations

Kyphoplasty cannot correct an established deformity of the spine and certain patients with osteoporosis are not candidates for this treatment. The decision to perform this procedure should be multidisciplinary, taking 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. Prior to performing the kyphoplasty the specialist must ensure that the pain is caused by a compression fracture and not due to some other reason.

It is expected that only those skilled in this technique will perform it. Rapid access to emergency equipment and personnel is required.

Kyphoplasty is contraindicated in:

osteomyelitis or local infection
uncorrectable coagulopathy
allergy to the PMMA
retropulsed fracture fragment or tumor mass causing
significant spinal canal compromise
extensive and/or significant vertebral collapse or destruction (relative contraindications)

Kyphoplasty is not covered for:

non-painful stable vertebral compression fractures (VCFs),
osteoporotic VCFs responding to conservative therapy,
established deformities (> 10 weeks from estimated
occurrence of the fracture unless MRI documents significant ongoing vertebral edema), or
use as a prophylactic procedure for osteoporosis.
chronic back pain of long-standing duration even if associated with old compression fractures.

Coverage Topic ^{back
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Surgical Services

Coding Information

Bill Type Codes: ^{back
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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: ^{back
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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.

0360	Operating room services-general classification

CPT/HCPCS Codes ^{back
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The following codes are effective until 01/01/2006
C9718
C9719
The following codes are effective 01/01/2006

22523	PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, ONE 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, ONE 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, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

ICD-9 Codes that Support Medical Necessity ^{back
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170.2	MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX
198.5	SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
203.00 - 203.01	MULTIPLE MYELOMA WITHOUT REMISSION - MULTIPLE MYELOMA IN REMISSION
213.2	BENIGN NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX
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 ^{back
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ICD-9 Codes that DO NOT Support Medical Necessity ^{back
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ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back
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Diagnoses that DO NOT Support Medical Necessity ^{back
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General Information

Documentation Requirements ^{back
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1. Medical record documentation must indicate the medical necessity for performing this service and must support that the service was performed:

History and Physical
MD order/progress notes for services rendered
Pertinent Test reports with written interpretation
Office/progress reports
Prior treatment(s) and patient response
Procedure records (specifying the number of each vertebral body treated (e.g., "t-12, L1").
Itemization of charges

2. When the service is performed for painful, debilitating, osteoporotic vertebral collapse/compression fractures, documentation must support that conservative treatment has failed.

Appendices ^{back
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LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines ^{back
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Sources of Information and Basis for Decision ^{back
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"Kyphoplasty" Draft Policy by First Coast Service, Inc, Part A

"Balloon Assisted Percutaneous Vertebroplasty" Policy by Trailblazer Health Enterprises, LLC, Part A, 12/16/01.

Lieberman IH, Dudeney S, Reinhardt M-K, Bell G: Initial Outcome and Efficacy of "Kyphoplasty" in the Treatment of Painful Osteoporotic Vertebral Compression Fractures. Spine, Vol 26, No14, 2001.PA

Brown, Courtney MD and Wong, Douglas MD. Kyphoplasty-a new treatment for osteoporotic fractures/Spine Health Research. Jan'01.

Advisory Committee Meeting Notes ^{back
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Public Open Meeting to discuss the draft policy was held 07/09/2002.

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from orthopedics as well as provider (facility) representatives.

Start Date of Comment Period ^{back
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06/05/2002

End Date of Comment Period ^{back
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07/20/2002

Start Date of Notice Period ^{back
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08/13/2002

Revision History Number ^{back
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L1941a

Revision History Explanation ^{back
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11/06/2002 Added the remark requirement under section CPT/HCPCS Codes and Other Comments.

02/17/2005 CMS Pub 100-4 Transmittal 423 CR3632. Added HCPCS codes C9718/C9719 and deleted 22520, 22521, 22522 from CPT/HCPCS Group 1.

11/26/2005 - CPT/HCPCS code C9718 was deleted from group 1
11/26/2005 - CPT/HCPCS code C9719 was deleted from group 1

This LCD was converted from an LMRP on 12/8/2005

Last Reviewed On Date ^{back
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06/21/2007