Mountain State Medical Policy Bulletin

Section: Surgery
Number: S-148
Topic: Kyphoplasty
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Kyphoplasty (S2362, S2363) is a procedure done percutaneously with use of an inflatable balloon bone tamp to help correct deformity of collapsed vertebral body and to create a controlled space into which bone cement is injected.  This procedure is eligible when performed for any of these 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;
  • reinforcement of a pathologically weak vertebral body before a surgical stabilization procedure; and,
  • kyphosis.

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

Description

Balloon kyphoplasty is the minimally invasive reduction and fixation of vertebral body compression fractures (VCF) designed to provide significant pain relief, fracture reduction and stabilization, restoration of vertebral height, and reduction of spinal deformity.

Vertebral compression fracture (VCF) is the most common fracture caused by osteoporosis. Osteoporosis is recognized as one of the major public health problems facing postmenopausal women and aging individuals of both sexes. Historically, conventional methods of treatment for VCF have included bed rest, the use of narcotics, and braces. However, as an alternative to these conventional methods of treatment, a percutaneous procedure called kyphoplasty can be performed.


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.

Procedure Codes

S2362S2363    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

12/2001, Kyphoplasty considered investigational
10/2003, Reporting guidelines for balloon kyphoplasty

References

National Blue Cross and Blue Shield Association TEC Assessment: Vol. 18, No. 1, 01/2000

An Invivo Comparison of the Potential for Extravertebral Cement Leak After Vertebroplasty and Kyphoplasty, Spine, Vol. 27, No. 19, 2002

Percutaneous Balloon Kyphoplasty for the Correction of Spinal Deformity in Painful Vertebral Body Compression Fractures, Journal of Clinical Imaging, Vol. 26, 2002

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Glossary





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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.