Kyphoplasty (22523, 22524, 22525) 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. Effective January 26, 2009, a participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

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.

This 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.

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