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. Services that were not medically reasonable and necessary will be denied and will result in an overpayment.
Affected Code(s)
22510, 22511, 22512, 22513, 22514, 22515, 20225, 22310, 22315, 22325, 22327
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. CGS LCD L34048- Vertebroplasty and Vertebral Augmentation (Percutaneous); Effective 10/01/2015; Retired 11/17/2019
9. CGS LCD L38201- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/18/2019, Revised 10/6/2022
10. CGS LCA A57282- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/18/2019; Revised 10/6/2022
11. First Coast Service Options (FCSO) LCD L34976- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 7/11/2021
12. NGS LCD L33569- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 12/01/2020
13. NGS LCA A56178- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 12/01/2020
14. Noridian LCD L34106- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 01/10/2021
15. Noridian LCD L34228- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 01/10/2021
16. Noridian LCA 56572- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/1/2019; Revised 01/10/2021
17. Noridian LCA 56573- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/1/2019; Revised 01/10/2021
18. Novitas LCD- L35130 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 7/11/2021
19. Novitas LCA 57752- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/21/2019; Revised 7/12/2020
20. Palmetto LCD L33473- Vertebroplasty/Kyphoplasty; Effective 10/01/2015; Retired 11/27/2021
21. Palmetto GBA LCA A56819- Billing and Coding: Vertebroplasty/Kyphoplasty; Effective 8/8/2019; Retired 11/27/2021
22. WPS LCD L34592- Vertebroplasty (Percutaneous) and Vertebral Augmentation including cavity creation; Effective 10/01/2015; Retired 12/15/2019
23. WPS LCD L38213- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 12/16/2019; Revised 9/01/2022
24. WPS LCA A57630- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 12/16/2019; Revised 9/01/2022
25. Annual American Medical Association: CPT Manual