CurrentKaiser PermanentePolicy N/A

Clinical Review Vertebroplasty Kyphoplasty Ga

Defines indications, contraindications and utilization management review criteria for vertebroplasty (percutaneous vertebral augmentation) and kyphoplasty for vertebral compression fractures, malignant lesions, and vertebral hemangiomas for the Georgia region Quality Resource Management staff.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Vertebroplasty Kyphoplasty Ga

Policy CodePolicy N/A

Change TypeReviewed/Revised (8/8/2024)

Effective DateMay 19, 2005

Next Review Date

Key ActionDocument lack of significant response to conservative measures (NSAIDs, narcotics, back brace, activity modification) over 3-6 weeks and inability to perform ADLs due to pain.

SourceLink

POLICY UPDATE CHANGES

Last revision date documented as 8/8/2024 with criteria reviewed/revised.

3Covered Clinical Indication Categories (osteoporotic, malignant, hemangioma)

6Key Contraindications Listed

3Primary Procedural Codes Listed

Coverage Summary

This policy addresses vertebral augmentation procedures (percutaneous vertebroplasty and kyphoplasty) which involve image‑guided injection of polymethylmethacrylate (PMMA) into fractured vertebral bodies to relieve pain and stabilize the spine. It applies to the Georgia Quality Resource Management (QRM) program and defines indications, contraindications, documentation and utilization management review requirements used by QRM staff. The overall coverage stance is Covered with criteria, with specific medical necessity criteria and prior‑authorization review described in the policy.

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Medical-Necessity Criteria

Medically Necessary Indications - Osteoporotic Vertebral Compression Fracture

Covered when ALL of the following are met:

ALL of the following

Osteoporotic vertebral compression fracture
Subacute compression fracture requiring hospitalization, narcotics administration with decreased ability to perform ADL's
No significant response to conservative measures over 3-6 weeks (e.g., NSAIDs, narcotics, back brace, activity modification) with inability to perform ADL's due to the painConservative therapy duration: 3-6 weeks
Vertebroplasty noted as option for patients with back pain refractory to medical therapy over 3-6 weeks; kyphoplasty also option and may be outpatient with possible 23-hour stay or inpatient if admitted for pain control
No neurologic compromise
MRI confirms continuing edema in the vertebral body (fracture < 6 months old)Fracture acuity by MRI: < 6 months

Medically Necessary Indications - Malignancy-related Compression Fracture

Covered when ALL of the following are met:

ALL of the following

Malignancy-related compression fracture (subacute or acute) requiring hospitalization, narcotics administration with decreased ability to perform ADL's
No significant response to conservative measures over 3-6 weeks (e.g., NSAIDs, narcotics, back brace, activity modification) with inability to perform ADL's due to the painConservative therapy duration: 3-6 weeks
Malignant osseous mass comprising a significant portion of the vertebral body (document extent of vertebral body destruction)
Provide imaging documenting extent of vertebral body destruction
No neurologic compromise

Medically Necessary Indications - Vertebral Hemangioma

Covered when ALL of the following are met:

ALL of the following

Vertebral hemangioma comprising 50% or more of the vertebral body with a compression fractureVertebral hemangioma size: ≥50% of vertebral body
No significant response to conservative measures over 3-6 weeks (e.g., NSAIDs, narcotics, back brace, activity modification) with inability to perform ADL's due to the painConservative therapy duration: 3-6 weeks
No neurologic compromise
OR

Contraindications (Not Medically Necessary / Exclusions)

Not covered when ANY of the following are present:

ANY of the following

Patients improving on medical therapy
Ongoing local or systemic infection including osteomyelitis of involved vertebrae
Spinal cord or nerve root compression
Spinal canal compromise secondary to malignancy resulting in myelopathy
Uncorrectable coagulopathy

Operational / Selection Considerations

Additional clinical considerations to guide selection:

ALL of the following

Patient selection is critical; vertebral augmentation not indicated for mild-to-moderate pain responding to medical management
Vertebroplasty may be preferred for select subsets (e.g., endplate fractures); it is technically easier and less expensive than kyphoplasty
Kyphoplasty may improve care, decrease hospitalization and decrease recurrent fractures in selected patients; choice of procedure is dictated by practitioner expertise

Provider Actions & Prior Authorization

Prior Authorization

Utilization Management review required

QRM staff to review medical necessity per criteria prior to approval; policy used by QRM to make decisions.

Documentation Required

Document failed conservative management

Document lack of significant response to conservative measures over 3-6 weeks and inability to perform ADLs due to pain.

Documentation Required

Imaging confirmation

Provide MRI confirmation of vertebral body edema (fracture < 6 months old) or imaging ruling out other causes; document extent of vertebral body destruction for malignancy cases.

Billing Rule

Report specified CPT/HCPCS codes

When approved, bill using the listed CPT/HCPCS codes as appropriate.

S2360-61
22523-22525

Background & Evidence

Vertebral augmentation includes two primary procedures: vertebroplasty, which percutaneously injects bone cement (PMMA) into the collapsed vertebral body under CT or fluoroscopic guidance to alleviate pain and strengthen the vertebra, and kyphoplasty, which uses an inflatable bone tamp (balloon) to restore vertebral height before cement placement. Kyphoplasty is noted as significantly more expensive than vertebroplasty; vertebroplasty is technically easier and less expensive and may be preferred for some fracture patterns (for example, endplate fractures). Both procedures are usually performed in an outpatient setting with sedation or general anesthesia; kyphoplasty can be scheduled as an outpatient and may require a 23‑hour stay, or be performed inpatient if the patient is admitted for pain control. The policy also notes typical risks (infection, bleeding, cement leakage, pulmonary embolus, rare neurologic deficits) and an approximately 80% reported improvement rate in pain after vertebroplasty.

Evidence summary

Definitions & operational notes

OpenPayer

Clinical Review Vertebroplasty Kyphoplasty Ga

Coverage Summary

Medical-Necessity Criteria

Provider Actions & Prior Authorization

Coding

Background & Evidence

Revision History

S2360-61	Percutaneous vertebral augmentation procedure codes (site-specific S-code listed in document)
22523-22525	Vertebral augmentation/related spine codes listed in document