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 Administrators, LLC, LCD L38201- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/18/2019; Revised 10/5/2023
9. CGS Administrators, LLC, LCA A57282- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/18/2019; Revised 11/22/2023
10. First Coast Service Options, Inc., LCD L34976- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 7/11/2021
11. National Government Services, Inc., LCD L33569- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 12/01/2020
12. National Government Services, Inc., LCA A56178- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 12/01/2020
13. Noridian Healthcare Solutions, LLC, LCD L34106- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 01/10/2021
14. Noridian Healthcare Solutions, LLC, LCD L34228- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 01/10/2021
15. Noridian Healthcare Solutions, LLC, LCA A56572- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 01/10/2021
16. Noridian Healthcare Solutions, LLC, LCA A56573- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 01/10/2021
17. Novitas Solutions, Inc., LCD L35130- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 7/11/2021
18. Novitas Solutions, Inc., LCA A57752- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/21/2019; Revised 7/12/2020
19. Palmetto GBA LCD L38737- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/28/2021; Revised 7/20/2023
20. Palmetto GBA LCA A58275- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/28/2021; Revised 8/21/2022
21. Wisconsin Physicians Service Insurance Corp., LCD L38213- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 12/16/2019; Revised 9/01/2022
22. Wisconsin Physicians Service Insurance Corp., LCA A57630- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 12/16/2019; Revised 9/01/2022
23. AMA CPT Codebook