Utilization Review Checklist
Cervical and Thoracic Vertebral Compression Fracture — Vertebroplasty and Kyphoplasty
Derived from the ACOEM Cervical and Thoracic Spine Disorders Guideline, edition 17 October 2018, as adopted into the California MTUS 18 April 2019. CPT 22510, 22511, 22513, 22514. ICD-10 M80.08, M80.88, S22.000, M84.48.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Presumptive Diagnosis
Required
Cervical or thoracic pain due to a vertebral compression fracture
“Vertebroplasty is not recommended as a routine treatment for patients with cervical or thoracic pain due to vertebral compression fractures.” — p. 114
Conservative Care(informational — not scored)
Required
Severe pain, passage of at least 2 months, and failure of other treatment options including medical management (select-patient vertebroplasty only) — at least 2 months
“should generally have severe pain, passage of at least 2 months, and failure of other treatment options including medical management.” — p. 114
Procedures — the guideline treats each separately
Vertebroplasty as routine treatment — subacute or chronic cervical or thoracic compression fracture
Strongly Not Recommended. Vertebroplasty is not recommended as a routine treatment for patients with cervical or thoracic pain due to vertebral compression fractures.
Strength of Evidence — Strongly Not Recommended, Evidence (A) [Subacute, Chronic] · confidence high · p. 114
Indications — required:
The guideline strongly advises against routine vertebroplasty in subacute and chronic presentations
“Vertebroplasty is not recommended as a routine treatment for patients with cervical or thoracic pain due to vertebral compression fractures.” — p. 114
Strongly NOT recommended at High confidence.
Vertebroplasty as routine treatment — acute cervical or thoracic compression fracture
Not Recommended. Strength of Evidence – Not Recommended, Evidence (C) [Acute]
Strength of Evidence — Not Recommended, Evidence (C) [Acute] · confidence moderate · p. 114
Indications — required:
The guideline advises against routine vertebroplasty in acute presentations, at a lower grade
“Strength of Evidence – Not Recommended, Evidence (C) [Acute]” — p. 114
Not recommended, at a lower grade than the subacute and chronic case. State the fracture date so the right grade is applied.
Vertebroplasty for highly select patients with unusual compression fractures
No Recommendation. There is no recommendation for or against the use of vertebroplasty for treatment of highly select patients with cervical or thoracic pain due to unusual vertebral compression fractures.
Strength of Evidence — No Recommendation, Insuffcient Evidence (I) · confidence low · p. 114
Indications — any one of the following:
Fracture despite bisphosphonate therapy
“These include patients who have had fractures despite bisphosphonate therapy” — p. 114
OR
Pathologic fracture due to neoplasm in the vertebral body
“pathologic fractures due to neoplasms” — p. 114
OR
Multiple simultaneous compression fractures (three or more) — at least 3
“or multiple simultaneous compression fractures (three or more)” — p. 114
No recommendation either way. Meeting the indications places the request in the group the guideline declines to rule on — it does not make the procedure recommended.
Kyphoplasty for cervical or thoracic pain due to vertebral compression fractures
No Recommendation. There is no recommendation for or against the use of kyphoplasty as a treatment for patients with cervical or thoracic pain due to vertebral compression fractures.
Strength of Evidence — No Recommendation, Insuffcient Evidence (I) · confidence low · p. 115
Indications — required:
Vertebral body compression fracture with severe pain
“Indications – Vertebral body compression fractures among patients with severe pain; patients who have had fractures despite bisphosphonate therapy may be candidates.” — p. 115
No recommendation for or against.