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Issue Number - Name
0139-Complex Medical Necessity Vertebroplasty and Kyphoplasty (Vertebral Augmentation)
Review Type
Complex
Claim Type
Outpatient Hospital (OPH), Ambulatory Surgery Center (ASC), Physician/Non-physician Practitioner (NPP)
Region and State
RAC 1-4
All A/B MACs
Date Approved
02/12/2019

Description

Vertebroplasty and kyphoplasty will be reviewed for medical necessity whether billed as an initial procedure, a repeat procedure (beyond once in a lifetime) or if performed at more than one vertebral level.

Affected Codes

CPT codes 22510, 22511, 22512, 22513, 22514, 22515 (2018)
CPT codes 22520, 22521, 22522, 22523, 22524, 22525 (prior years)

Applicable Policy References

Title XVIII, Social Security Act (SSA): Sections 1833(e), 1862(a)(1)(A), 1862(a)(10)
42 CFR Sections 405.980(b) and (c), 405.986, 411.15(k)(1), 424.5(a)(6)
CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, Sections 10, 20
First Coast Service Options (FCSO) LCD L34976, Effective 10/01/2015, Revised 4/17/18
Novitas LCD L35130, Effective 10/01/2015, Revised 05/04/2017
Palmetto LCD L33473, Effective 10/01/2015, Revised 08/09/2018
WPS LCD L34592, Effective 10/01/2015, Revised 2/1/18
NGS LCD L33569, Effective 10/01/2015
FCSO A55960, Effective 10/01/2015
Noridian LCD, Percutaneous Vertebral Augmentation, L34106, Effective 10/01/2015
Noridian LCD, Percutaneous Vertebral Augmentation, L34228, Effective 10/01/2015
CGS LCD, Vertebroplasty and Vertebral Augmentation, L34048, Effective 10/01/2015
Annual American Medical Association: CPT Manual