LCD : Percutaneous Vertebroplasty (L1959)

LCD for Percutaneous Vertebroplasty (L1959)

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
to top}

L1959

LCD Title ^{back
to top}

Percutaneous Vertebroplasty

Contractor's Determination Number ^{back
to top}

L1959

AMA CPT / ADA CDT Copyright Statement ^{back
to top}

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
to top}

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
to top}

New Jersey
Tennessee

Secondary Geographic Jurisdiction ^{back
to top}

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region ^{back
to top}

Region IV

Original Determination Effective Date ^{back
to top}

For services performed on or after 09/29/2002

Original Determination Ending Date ^{back
to top}

Revision Effective Date ^{back
to top}

For services performed on or after 12/09/2005

Revision Ending Date ^{back
to top}

Indications and Limitations of Coverage and/or Medical Necessity ^{back
to top}

Percutaneous vertebroplasty is a therapeutic orthopedic procedure that involves injection of bone cement into a thoracic or lumbar vertebral body for the relief of pain and the strengthening of bone. This procedure is being used for patients with lytic lesions due to bone metastases, aggressive hemangiomas, multiple myeloma, and for patients who have medically intractable debilitating pain resulting from osteoporotic vertebral collapse.

The procedure is performed using x-ray guidance to accurately inject a medical grade cement, polymethylmethacrylate (PMMA), into a partially compressed vertebral body. The procedure is performed under general anesthesia or conscious sedation with additional local anesthesia and usually lasts from 1-2 hours, unless the cement is injected into two or more vertebral bodies. The patient must remain flat for about three hours following the procedure.

The Least You Need to Know

Percutaneous vertebroplasty is covered for the treatment intractable and debilitating symptoms of thoracic and lumbar collapsed vertebrae. Conservative treatment must have failed, other causes of pain must be ruled out, and the vertebral body must retain at least one third of its original height. It is not covered as a prophylactic procedure for osteoporosis.

Indications

Percutaneous vertebroplasty is considered appropriate treatment for patients with vertebral lesions resulting from osteolytic metastasis, multiple myeloma, hemangioma, or osteonecrotic osteoporotic compression fractures if the following criteria have been met:

Severe debilitating pain or loss of mobility that cannot be relieved by two to four weeks of conservative medical therapy (e.g., a period of immobilization such as restricted activity/bracing and analgesia/scheduled narcotic).
Other causes of pain, such as herniated intervertebral disk, have been ruled out by computed tomography or magnetic resonance imaging.
The affected vertebra has not been extensively destroyed and is at least one third of its original height.

Limitations

Patient selection is critical because the treatment is specific for pain associated with simple vertebral fracture and compression. This treatment should not be utilized nor expected to be effective for the treatment of degenerative disc disease, herniated disc, or compression of the spinal cord or its associated nerve roots. Vertebral bodies must retain a significant portion of their original height as identified on standard x-rays if successful injection of the medical cement is to be expected. A neurologic examination should not demonstrate any evidence of nerve compression.

The decision to perform this procedure should be multidisciplinary, taking into consideration 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.

Vertebroplasty is contraindicated in:

Patients with infection of the area
Patients with coagulation disorders (due to the large diameter of the needles used for injection).
Patients with extensive vertebral destruction (relative contraindication)
Patients with neurological symptoms related to compression (relative contraindication)
Situations in which there is no surgical backup for emergency decompression in the event a neurological deficit develops during the injection of polymethylmethacrylate.

Vertebroplasty is not covered in:

Patients with significant vertebral collapse (i.e., vertebra reduced to less than one-third its original height)
Chronic back pain except when a specific vertebral collapse has been identified as a source of the pain
Patients undergoing a prophylactic procedure for osteoporosis of the spine.

Coverage Topic ^{back
to top}

Surgical Services

Coding Information

Bill Type Codes: ^{back
to top}

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
to top}

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
to top}

22520	PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; THORACIC
22521	PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR
22522	PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

ICD-9 Codes that Support Medical Necessity ^{back
to top}

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
228.09	HEMANGIOMA OF OTHER SITES
238.6	NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS
239.2	NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN
721.7	TRAUMATIC SPONDYLOPATHY
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
to top}

ICD-9 Codes that DO NOT Support Medical Necessity ^{back
to top}

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back
to top}

Diagnoses that DO NOT Support Medical Necessity ^{back
to top}

General Information

Documentation Requirements ^{back
to top}

Medical record documentation must indicate the medical necessity for performing this service. The documentation must also 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

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

Appendices ^{back
to top}

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines ^{back
to top}

Sources of Information and Basis for Decision ^{back
to top}

"Percutaneous Vertebroplasty" Draft Policy by First Coast Service, Inc, Part A

"Percutaneous Vertebroplasty" Final Policy by Empire Medicare Services, NY

"Percutaneous Vertebroplasty/Kyphoplasty" Final Policy by Empire Medicare Services, NJ

Susan A. Levine, D.V.M., Ph.D., Lawrence A. Perin, M.D., M.B.A.*, Diane Hayes, Ph.D.�, Winifred S. Hayes, Ph.D.� "An Evidence-Based Evaluation of Percutaneous Vertebroplasty". MANAGED CARE/Journal Article;Meta-Analysis. March 2000. �2000 MediMedia USA.

Guelbenzu S; Gomez J; Garcia-Asencio S; Barrena R; Ferrandez D - "Percutaneous vertebroplasty in Hemangioma compression": Rev Neurol-1999 Feb 16-28; 28(4).

New Codes for Percutaneous Vertebroplasty" SPPM-Society for Pain Practice Management.

"Osteoporosis" MD Consult - Patient Education Handout. Nidus Information Services 2001.

Advisory Committee Meeting Notes ^{back
to top}

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.