Mountain State Medical Policy Bulletin |
Section: | Surgery |
Number: | S-146 |
Topic: | Percutaneous Vertebroplasty |
Effective Date: | January 1, 2007 |
Issued Date: | September 10, 2007 |
Date Last Reviewed: | 12/2006 |
Indications and Limitations of Coverage
Percutaneous vertebroplasty is an eligible procedure when performed for any of the following indications:
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. |
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22520 | 22521 | 22522 | 72291 | 72292 | S2360 |
S2361 |
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 |
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