Kyphoplasty/Vertebroplasty, Thoracic Spine

Home , Osteotomy, Spinal fusion, Vertebral augmentation

Musculoskeletal Surgical Services: Spine Fusion/Stabilization Surgery; Kyphoplasty/Vertebroplasty, Thoracic Spine

POLICY INITIATED: 06/30/2019 MOST RECENT REVIEW: 06/30/2019 POLICY # HH-5641

Overview Statement The purpose of these clinical guidelines is to assist healthcare professionals in selecting the medical service that may be appropriate and supported by evidence to improve patient outcomes. These clinical guidelines neither preempt clinical judgment of trained professionals nor advise anyone on how to practice medicine. The healthcare professionals are responsible for all clinical decisions based on their assessment. These clinical guidelines do not provide authorization, certification, explanation of benefits, or guarantee of payment, nor do they substitute for, or constitute, medical advice. Federal and State law, as well as member benefit contract language, including definitions and specific contract provisions/exclusions, take precedence over clinical guidelines and must be considered first when determining eligibility for coverage. All final determinations on coverage and payment are the responsibility of the health plan. Nothing contained within this document can be interpreted to mean otherwise. Medical information is constantly evolving, and HealthHelp reserves the right to review and update these clinical guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from HealthHelp. All trademarks, product names, logos, and brand names are the property of their respective owners and are used for purposes of information/illustration only.

Associated Procedure Codes: Procedure Code Description Code Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral 22206 segment (eg, pedicle/vertebral body subtraction); thoracic Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; 22212 thoracic Osteotomy of spine, including discectomy, anterior approach, single vertebral 22222 segment; thoracic Percutaneous vertebral augmentation, including cavity creation (fracture reduction 22513 and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

Clinical Guidelines for Medical Necessity Review of Musculoskeletal Surgical Services. http://www.healthhelp.com | © 2019 HealthHelp. All rights reserved. 16945 Northchase Dr #1300, Houston, TX 77060 (281) 447‐7000

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare 22532 interspace (other than for decompression); thoracic Arthrodesis, anterior interbody technique, including minimal discectomy to prepare 22556 interspace (other than for decompression); thoracic Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral 22610 transverse technique, when performed) Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral 22800 segments Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral 22802 segments Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral 22804 segments Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral 22808 segments Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral 22810 segments Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral 22812 segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) 22818 (including body and posterior elements); single or 2 segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) 22819 (including body and posterior elements); 3 or more segments Reinsertion of spinal fixation device 22849 Removal of posterior nonsegmental instrumentation (eg, Harrington rod) 22850 Removal of posterior segmental instrumentation 22852 Removal of anterior instrumentation 22855 Removal of posterior nonsegmental instrumentation (eg, Harrington rod) 22850 Removal of posterior segmental instrumentation 22852 Removal of anterior instrumentation 22855

Definition: 1. A vertebroplasty is a minimally-invasive technique that can be used to treat both lumbar and thoracic compression fractures. Like a cast for a broken bone, a vertebroplasty will immediately stabilize the fracture, relieve pain and prevent the formation of a deformity. A kyphoplasty is a similar procedure designed to stabilize compression fractures. It’s sometimes called a balloon vertebroplasty, because it involves inflating the fracture with a balloon.

Guideline: . The use of thoracic kyphoplasty or vertebroplasty may be appropriate and supported by evidence to improve outcomes for patients when the patient’s medical record demonstrates the following: o Persistent thoracic pain and/or deformity; and EITHER of the following: (1)  Treatment plan consists of treatment to 2 or less vertebrae; and ANY of the following: □ Hemangiomas in the thoracic spine and radiation therapy not effective

at relieving pain; (2, 10) □ History of metastatic disease to the spine or myeloma and neither radiation therapy nor chemotherapy has been effective in relieving pain;

(1, 10) □ CT or MRI confirm osteoporotic or pathologic fracture; and BOTH of the

following: (3,4,5,6,7,8,9)

 Patient has had a trial of bracing for at least eight (8) weeks; (3,4,5,7,9)  At least eight (8) weeks of analgesic or anti-inflammatory medications or patient has a documented contraindication to

analgesic or anti-inflammatory medications. (3,4,5,6,7)

References 1. Carragee EJ, et al. (2008). Treatment of neck pain. Injections and surgical interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 33(4S): S153-S169. 2. Trends in the Treatment of Single and Multilevel Cervical Stenosis, Alfredo Arrojas - J. Jackson - Gregory Grabowski - The Journal of Bone and Joint Surgery – 2017 3. Surgical versus non-surgical treatment for lumbar spinal stenosis, Fabio Zaina - Christy Tomkins-Lane - Eugene Carragee - Stefano Negrini - Cochrane Database of Systematic Reviews – 2012 4. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spine 2012;37(1):67–76. The Spine Journal – 2012 5. Utilization of Lumbar Spinal Fusion in New York State Jeffrey Jancuska - Lorraine Hutzler - Themistocles Protopsaltis - John Bendo - Joseph Bosco - Spine – 2016 6. Vertebroplasty and Kyphoplasty: National Outcomes and Trends in Utilization from 2005 Through 2010 Vadim Goz - Thomas Errico - Jeffrey Weinreb - Steven Koehler - Andrew Hecht - Virginie Lafage - Sheeraz Qureshi - The Spine Journal – 2013 7. Comparative analysis of clinical outcomes in patients with osteoporotic vertebral compression fractures (OVCFs): conservative treatment versus balloon kyphoplasty, Hwan Lee - Si Park - Soon Lee - Seung Suh - Jae Hong - The Spine Journal – 2012 8. Peer review report 2 on “Percutaneous Vertebroplasty Versus Conservative Treatment for Osteoporotic Vertebral Compression Fractures: An Updated Meta-analysis of Prospective Randomized Controlled Trials” International Journal of Surgery – 2017 9. Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials. Anne Mannion - Jens Brox - Jeremy Fairbank - The Spine Journal – 2013 10. Milliman Report. 11. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. 2011. Available from: https://www.ncbi.nlm.nih.gov/books/NBK82899/ 12. https://www.nuvopainmanagement.com/procedures/kyphoplasty-vertebroplasty/