Percutaneous vertebroplasty is an eligible procedure when performed for any of the following indications:

• osteoporotic vertebral compression fractures more than two weeks old in the cervical, thoracic, and lumbar spine causing moderate to severe pain and unresponsive to conservative therapy;
• painful metastasis and multiple lymphoma or myelomas with or without adjuvant radiation or surgical therapy;
• painful vertebral hemangiomas;
• vertebral osteonecrosis; and,
• reinforcement of a pathologically weak vertebral body before a surgical stabilization procedure.

Percutaneous vertebroplasty performed for any other indication(s) is considered not medically necessary and, therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied service. 

Description

Percutaneous vertebroplasty (codes 22520, 22521, 22522, S2360, S2361) is a minimally invasive, radiologically guided procedure used in the treatment of vertebral body compression fractures. This procedure involves the injection of polymethylmethacrylate (PMMA) cement into the collapsed vertebra. This is accomplished by advancing a large diameter needle through the skin and underlying tissue into the compressed vertebral body. Once the needle is positioned, PMMA is injected into the fractured bone with the intent to reinforce and stabilize the bone.

Radiological imaging is a critical part of this procedure. Either fluoroscopic guidance (code 72291) or computed tomography (code 72292) may be utilized.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

Vertebroplasty: Clinical Experience and Follow-up Results, Bone, Vol. 25, No. 2, 08/1999

Percutaneous Vertebroplasty for Pain Relief and Spinal Stabilization, Spine, Vol. 25, No. 8, 2000

The Strengthening Effect of Percutaneous Vertebroplasty, Clinical Radiology, Vol. 55, 2000

Percutaneous Vertebroplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: An Open Prospective Study, The Journal of Rheumatology, Vol. 26, 1999

Percutaneous Vertebroplasty: Long-Term Clinical and Radiological Outcome, Neuroradiology, Vol. 44, 2002

Prospective Evaluation of Pain Relief in 100 Patients Undergoing Percutaneous Vertebroplasty: Results and Follow-up, Journal of Vascular and Interventional Radiology, Vol. 13, No. 9, 2002

Occurrence of New Vertebral Body Fracture After Percutaneous Vertebroplasty in Patients with Osteoporosis, Vascular and Interventional Radiology, Vol. 226, No. 1, 2003

Asymptomatic Diffuse Pulmonary Embolism Caused by Acrylic Cement: An Unusual Complication of Percutaneous Vertebroplasty, Annals of Rheumatology Disease, Vol. 62, 2003