Vertebroplasty and Kyphoplasty Form

Percutaneous vertebroplasty and kyphoplasty are used for the treatment of osteoporotic compression fractures, painful vertebral hemangiomas, myeloma, and metastatic lesions. Both procedures involve the injection of bone cement under image guidance into the spinal fractures with the goal of relieving pain, improving mobility, and preventing further collapse of the bone.

For kyphoplasty, a low-pressure cavity is created in the fractured vertebral body by placement of an inflatable bone tamps. Bone cement is placed into this cavity to reduce the fracture and to possibly improve the kyphotic deformity.

Clinical Guideline Coverage Criteria

The Plan requires the use of the following InterQual® Subsets or SmartSheets to obtain prior authorization for vertebroplasty or kyphoplasty:

• Vertebroplasty
• Kyphoplasty

Codes