CurrentKaiser PermanentePolicy No.01-35

Vertebroplasty and Kyphoplasty (Vertebral Augmentation)

Defines indications, contraindications, and utilization management criteria for percutaneous vertebroplasty and kyphoplasty for vertebral compression fractures for the Georgia Region of Kaiser Permanente.

Policy Summary

PayerKaiser Permanente

PolicyVertebroplasty and Kyphoplasty (Vertebral Augmentation)

Policy CodePolicy No.01-35

Change TypeReviewed/Revised

Effective DateMay 19, 2005

Next Review Date

Key ActionObtain prior authorization and document failure of conservative therapy for 3-6 weeks, MRI evidence of vertebral body edema (<6 months), and absence of neurologic compromise.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-6 weeksconservative therapy trial

<6 monthsMRI edema timeframe

80%reported improvement rate

220 psikyphoplasty max pressure

S2360-61, 22523-25listed codes

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Coverage Criteria — Vertebral Augmentation

Initial Coverage Criteria

Covered when ALL of the following are met for osteoporotic or malignant compression fractures:

Primary indications: Symptomatic vertebral compression fracture (osteoporotic or malignancy-related) causing debilitating pain or a subacute/acute fracture requiring hospitalization with narcotics administration and decreased ability to perform activities of daily living (ADLs).

Supported for osteoporotic and malignant etiologies

Failure of conservative therapy: No significant response to conservative measures over 3-6 weeks (eg, NSAIDs, narcotics, back brace, activity modification) OR subacute/acute fracture requiring hospitalization where adequate pain control cannot be achieved without parenteral opioids.3-6 weeks

Exception for inpatient uncontrolled pain

Imaging: MRI confirms continuing edema in the vertebral body consistent with a fracture less than 6 months old (used to establish acuity for osteoporotic fractures).<6 months

Imaging requirement for acuity determination

Neurologic status: No neurologic compromise (no spinal cord or nerve root compression).

Neurologic compromise is a contraindication

Procedure selection and setting

Procedure selection and setting:

Procedure choice: Kyphoplasty may be chosen to improve patient care, decrease hospitalization, and decrease recurrent vertebral compression fractures in selected patients; vertebroplasty is an option for selected patients with back pain refractory to medical therapy and may be technically preferable or less expensive in some cases.

Choice guided by practitioner expertise and patient factors

Setting: Kyphoplasty can be scheduled as an outpatient procedure with Interventional Radiology and may require a 23-hour stay; if the patient is admitted for pain control the procedure may be performed as an inpatient with discharge often the day after the kyphoplasty. Vertebroplasty is used in selected patients and practice patterns vary by region and practitioner expertise.23-hour stay possible

Operational note on setting and expected disposition

Explicit contraindications and exclusionary considerations include patients who are improving on medical therapy, those with ongoing local or systemic infection (including osteomyelitis of the involved vertebrae), and patients with spinal cord or nerve root compression or spinal canal compromise from malignancy resulting in myelopathy. Uncorrectable coagulopathy and chronic back pain of long-standing duration are also listed as conditions that would preclude vertebral augmentation.

Vertebral augmentation is not indicated for patients with mild-to-moderate pain that is responding to medical management. Patient selection should prioritize those with incapacitating pain unresponsive to conservative care. The guideline supports vertebral augmentation for patients with acute or subacute fractures who cannot taper parenteral opioids within seven days of admission or who have intolerable opioid-related adverse effects, and for those without improvement after timely conservative management (typically four to six weeks) or who are intolerant of oral opioids.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed CPT/HCPCS procedure codes. Requests must demonstrate that coverage criteria are met and include the required clinical documentation described below.

Affected codes: S2360, S2361, 22523, 22524, 22525
Submit PA request to Kaiser Permanente prior to scheduling the procedure

Billing Rule

Conservative Therapy Prerequisite

Conservative therapy is expected prior to vertebral augmentation unless there is clear subacute fracture evidence or other urgent clinical justification. Documented failure or inadequate response to conservative measures for a period of 3–6 weeks is generally required.

Coding — CPT and HCPCS

Listed CPT/HCPCS Codesmixed

S2360	Percutaneous vertebroplasty or kyphoplasty (HCPCS S-code listed)
S2361	Percutaneous vertebroplasty or kyphoplasty (HCPCS S-code listed)
22523	Percutaneous vertebral augmentation (CPT range listed)
22524	Percutaneous vertebral augmentation (CPT range listed)
22525	Percutaneous vertebral augmentation (CPT range listed)

Definitions — Procedures

Vertebroplasty — definition and key points

DefinitionPercutaneous injection of polymethylmethacrylate (PMMA) bone cement into a collapsed vertebral body under CT or fluoroscopic guidance to alleviate pain and strengthen the vertebra.

Typical guidanceProcedure performed by an Interventional Radiologist using CT or fluoroscopic guidance to position the needle.

Clinical purposeTo reduce acute debilitating back pain and stabilize the fractured vertebra; studies report an ~80% improvement rate.

Potential complicationsInfection, bleeding, cement leakage, fracture of adjacent structures, allergic reactions, cement pulmonary embolus, and occasional neurologic deficits (each reported <1%).

Kyphoplasty — definition and key points

Definition

Background

Vertebral compression fractures may be asymptomatic but can also cause acute, sometimes debilitating back pain and loss of function. Vertebroplasty involves percutaneous injection of polymethylmethacrylate (PMMA) bone cement into a collapsed vertebral body under imaging guidance to reduce pain and stabilize the vertebra. Kyphoplasty uses an inflatable bone tamp to attempt height restoration of the fractured vertebral body prior to PMMA cement injection; reported maximum balloon inflation pressures are up to 220 psi. Short-term pain relief following vertebral augmentation has been reported, though long-term benefit compared with conservative care remains uncertain.

Revision History

2005-05-19effective_date

Policy became effective.

2024-08-08last_revisionLatest

Policy reviewed/revised by Utilization Management Committee (last revision date recorded).

Policy Summary

PayerKaiser Permanente

PolicyVertebroplasty and Kyphoplasty (Vertebral Augmentation)

Policy CodePolicy No.01-35

Change TypeReviewed/Revised

Effective DateMay 19, 2005

Next Review Date

Key ActionObtain prior authorization and document failure of conservative therapy for 3-6 weeks, MRI evidence of vertebral body edema (<6 months), and absence of neurologic compromise.

SourceLink

On This Page

Examples of conservative therapy: NSAIDs, narcotics/opioids, bracing, activity modification, physical therapy

Typical prerequisite duration: 3–6 weeks (unless patient meets subacute fracture criteria with MRI evidence or is hospitalized with uncontrolled pain)

Documentation Required

Required Clinical Documentation

Provide comprehensive clinical documentation to support medical necessity. Documentation must specifically address failure of conservative measures for 3–6 weeks or provide evidence of a subacute fracture and describe clinical findings and imaging.

History of present illness including onset, severity, and impact on activities of daily living (ADLs)
Details of conservative treatments tried (medication names/doses, duration, brace use, physical therapy) and objective evidence of inadequate response
Neurologic exam documenting absence of significant neurologic compromise
Imaging reports: MRI showing persistent vertebral body edema consistent with fracture < 6 months old (if available); plain radiographs/CT as applicable
If inpatient, documentation of inability to taper parenteral opioids within seven days or intolerable opioid-related adverse effects

Denial Risk

Contraindications / Denial Risks

Cases with the following contraindications have a high risk of denial. Confirm absence of these contraindications in the submitted documentation.

Ongoing local or systemic infection, including osteomyelitis of the involved vertebrae
Spinal cord or nerve root compression
Spinal canal compromise resulting in myelopathy (eg, due to malignancy)
Uncorrectable coagulopathy
Patients who are clinically improving on medical therapy or have chronic long-standing back pain without acute/subacute fracture features

Percutaneous placement of an inflatable bone tamp (IBT) into the fractured vertebral body to restore height followed by PMMA bone cement injection.

Balloon inflationBalloon is inflated under fluoroscopy; maximum reported inflation pressure is 220 psi.

Technique detailsCannulated obturator and working cannula are used to create a corridor; IBT volume measured then removed before PMMA (with barium) injection; filling stopped when cement reaches two-thirds back to the posterior vertebral body cortex on lateral view.

Comparative noteKyphoplasty is significantly more expensive than vertebroplasty; choice guided by practitioner expertise and patient factors.