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Percutaneous vertebroplasty (PVP) is an interventional radiology technique involving the fluoroscopically guided injection of polymethylmethacrylate (PMMA) through a needle inserted into a weakened vertebral body. The technique has been investigated as an option to provide mechanical support and symptomatic relief in patients with osteoporotic vertebral compression fracture or in those with osteolytic lesions of the spine, i.e., multiple myeloma or metastatic malignancies. Percutaneous vertebroplasty has also been investigated as an adjunct to surgery for aggressive vertebral body hemangiomas, as a technique to limit blood loss related to surgery. Injection of PMMA is also being investigated for the treatment of sacral insufficiency fractures.
It has been proposed that vertebroplasty may provide an analgesic effect through mechanical stabilization of a fractured or otherwise weakened vertebral body. However, other possible mechanisms of effect have been postulated, including thermal damage to intraosseous nerve fibers.
Sacroplasty evolved from the treatment of insufficiency fractures in the thoracic and lumbar vertebrae with vertebroplasty. The procedure, essentially identical, entails guided injection of polymethylmethacrylate (PMMA) through a needle inserted into the fracture zone. While first described in 2000 as a treatment for symptomatic sacral metastatic lesions, it is most often described as a minimally invasive procedure employed as an alternative to conservative management for sacral insufficiency fractures (SIFs). SIFs are the consequence of stress on weakened bone and are often the cause of low back pain among the elderly. Osteoporosis is the most common risk factor for SIF.
Osteoporotic Vertebral Compression Fracture
Osteoporotic compression fractures are a common problem, and it is estimated that up to one-half of women and approximately one-quarter of men will have a vertebral fracture at some point in their lives. However, only about one-third of vertebral fractures actually reach clinical diagnosis, and most symptomatic fractures will heal within a few weeks or a month. However, a minority of patients will exhibit chronic pain following osteoporotic compression fracture that presents challenges for medical management. Chronic symptoms do not tend to respond to the management strategies for acute pain such as bed rest, immobilization/bracing device, and analgesic medication, sometimes including narcotic analgesics. The source of chronic pain after vertebral compression fracture may not be from the vertebra itself but may be predominantly related to strain on muscles and ligaments secondary to kyphosis. This type of pain frequently is not improved with analgesics and may be better addressed through exercise.
Sacral Insufficiency Fractures
Spontaneous fracture of the sacrum in patients with osteoporosis was described by Lourie in 1982 and presents as lower back and buttock pain with or without referred pain in the legs. Although common, SIFs can escape detection due to low provider suspicion and poor sensitivity on plain radiographs, slowing the application of appropriate intervention. Similar interventions are used for sacral and vertebral fractures including bed rest, bracing, and analgesics. Initial clinical improvements may occur quickly; however, the resolution of all symptoms may not occur for 9 to 12 months.
Vertebral/Sacral Body Metastasis
Metastatic malignant disease involving the spine generally involves the vertebrae/sacrum, with pain being the most frequent complaint. While radiation and chemotherapy are frequently effective in reducing tumor burden and associated symptoms, pain relief may be delayed days to weeks, depending on tumor response. Further, these approaches rely on bone remodeling to regain strength in the vertebrae/sacrum, which may necessitate supportive bracing to minimize the risk of vertebral/sacral collapse during healing.
Vertebral hemangiomas are relatively common lesions noted in up to 12% of the population based on autopsy series; however, only rarely do these lesions display aggressive features and produce neurological compromise and/or pain. Treatment of aggressive vertebral hemangiomas has evolved from radiotherapy to surgical approaches using anterior spinal surgery for resection and decompression. There is the potential for large blood loss during surgical resection, and vascular embolization techniques have been used as adjuncts to treatment to reduce blood loss. Percutaneous vertebroplasty has been proposed as a way to treat and stabilize some hemangioma to limit the extent of surgical resection and as an adjunct to reduce associated blood loss from the surgery.
Vertebroplasty is a surgical procedure and, as such, is not subject to U.S. Food and Drug Administration (FDA) approval. PMMA bone cement was available as a drug product prior to enactment of the FDA’s device regulation and was at first considered what the FDA terms a “transitional device.” It was transitioned to a class III device requiring premarketing applications. Several orthopedic companies have received approval of their bone cement products since 1976. In October 1999, PMMA was reclassified from class III to class II, which requires future 510(k) submissions to meet “special controls” instead of “general controls” to assure safety and effectiveness. Thus, use of PMMA in vertebroplasty represented an off-label use of an FDA-regulated product prior to 2005. In 2005, PMMA bone cements such as Spine-Fix® Biomimetic Bone Cement and Osteopal® V were issued 510(k) marketing clearance for the fixation of pathological fractures of the vertebral body using vertebroplasty or kyphoplasty procedures.
The use of PMMA in sacroplasty represents an off-label use of an FDA-regulated product (bone cements such as Spine-Fix® Biomimetic Bone Cement and Osteopal® V) as the 510(k) marketing clearance was for the fixation of pathological fractures of the vertebral body using vertebroplasty or kyphoplasty procedures. Sacroplasty was not included.
ArthroCare received FDA clearance for the Parallax® Contour® Vertebral Augmentation Device in 2010. The device creates a void in cancellous bone that can then be filled with bone cement.
Vesselplasty using Vessel-X®, (MAXXSPINE) and a similar procedure from A-Spine, are variations of vertebroplasty that are reported to reduce leakage of bone cement by containing the filler in an inflatable vessel. These devices do not have clearance for marketing by FDA.
Percutaneous Kyphoplasty is addressed in a separate policy.
POLICYPercutaneous vertebroplasty may be considered medically necessary for the treatment of symptomatic osteoporotic vertebral fractures that have failed to respond to conservative treatment (e.g., analgesics, physical therapy and rest) for at least 6 weeks.
Percutaneous vertebroplasty may be considered medically necessary for the treatment of severe pain due to osteolytic lesions of the spine related to multiple myeloma or metastatic malignancies.
Percutaneous vertebroplasty is considered investigational for all other indications, including use in acute vertebral fractures due to osteoporosis or trauma.
Percutaneous sacroplasty is considered investigational for all indications, including use in sacral insufficiency fractures due to osteoporosis and spinal lesions due to metastatic malignancies or multiple myeloma.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY2/2000: Approved by Medical Policy Advisory Committee (MPAC)
5/2000: Reviewed by MPAC; policy exceptions will be considered on an individual case basis
6/5/00 NOTE: See POLICY EXCEPTIONS and POLICY HISTORY.
11/2000: Reviewed by MPAC; investigational status maintained
1/17/2001: Code Reference section updated.
2/8/2002: Appeal statement deleted from Policy Exception section, Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/11/2002: CPT code 22899 deleted, HCPCS S2360 added
9/27/2002: Policy renamed "Percutaneous Vertebroplasty (PV) and Kyphoplasty", Description and Policy sections revised to be consistent with BCBSA policy, PMMA off-label use added, Sources and Code Reference sections updated
11/2002: Reviewed by MPAC; changed to medically necessary as treatment of vertebral compression fracture related to osteoporosis or as a treatment of osteolytic lesions of the spine relative to multiple myeloma or metastatic malignancies. Code Reference section updated
3/2003: Reviewed by MPAC, no changes, Sources updated
11/2003: Code Reference section updated, ICD-9 diagnosis code 238.9 deleted, ICD-9 diagnosis code range 733.00-733.09 listed separately
7/30/2004: Code Reference section updated, HCPCS S2361, S2362, S2363 added, Sources updated BCBSA policy # 6.01.38
7/21/2005: Reviewed by MPAC, no changes, Description section revised to be consistent with BCBSA policy # 6.01.25 & 6.01.38
9/21/2005: Code Reference section updated, ICD-9 procedure code 81.65, 81.66 added covered codes, “Note: This code is no longer used to report vertebroplasty and kyphoplasty effective 10-1-2004. For services on or after this date, see codes 81.65 and 81.66.” added ICD-9 procedure code 78.49
10/18/2005: Code Reference section updated, non-covered table deleted.
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy.
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions.
10/19/2007: Policy reviewed and investigational status given to all instances per BCBSA policy.
10/29/2007: Code reference section updated, non-covered table added. ICD-9 diagnosis codes 170.2, 198.5, 203.00, 203.01, 733.00, 733.01, 733.02, 733.03, 733.09 and 733.13 deleted. ICD-9 procedure code 78.49 deleted. Removed CPT codes 76012 and 76013 and HCPCS codes S2362 and S2363.
6/6/2008: Effective August 1, 2008, percutaneous vetebroplasty and kyphoplasty will be considered investigational for all indications.
9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied
10/28/2008: Percutaneous vertebroplasty and kyphoplasty separated into two distinct policies. Percutaneous vertebroplasty changed from investigational for all indication to medical necessary if not responding to conservative treatment or for severe pain due to osteolytic lesions of the spine related to multiple myeloma or metastatic malignancies. CPT 22520, 22521, 22522, 72291, 72292 moved to covered. HCPCS S2360 and S2361 moved to covered. ICD-9 procedure code 81.65 moved to covered. Added ICD-9 diagnosis codes 170.2, 198.5, 203.00-203.02, 238.0, 239.2, 733.00-733.09, 733.13.
11/20/2008: Approved by Medical Policy Advisory Committee (MPAC)
10/5/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
4/15/2010: Policy statement revised to add use in acute vertebral fractures due to osteoporosis or trauma is considered investigational. Code reference section updated. Description revised for CPT codes 72291 and 72292.
08/03/2011: Added "Sacroplasty" to the policy title. Policy description updated to add information regarding sacroplasty and sacral fractures. Added the following policy statement: Percutaneous sacroplasty is considered investigational for all indications, including use in sacral insufficiency fractures due to osteoporosis and spinal lesions due to metastatic malignancies or multiple myeloma. Added CPT codes 0200T and 0201T to the Non-Covered Codes table. Deleted outdated references from the Sources section.
04/26/2012: Policy reviewed; no changes.
08/07/2013: Policy reviewed; no changes.
07/11/2014: Policy reviewed; no changes.
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 22510, 22511, and 22512. Revised the description of the following CPT codes: 0200T and 0201T. Effective 01/01/2015.
08/26/2015: Code Reference section updated for ICD-10.
12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to removed deleted CPT codes 22520, 22521, 22522, 72291, and 72292.
03/03/2016: Policy description updated regarding devices. Policy statements unchanged. Sources section updated to remove reference.
SOURCE(S)Blue Cross & Blue Shield Association policy # 6.01.25
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.