Utilization Review Checklist
Vertebral Compression Fracture — Vertebroplasty and Kyphoplasty
Derived from the ACOEM Low Back Disorders Guideline, edition 13 February 2020, as adopted into the California MTUS 23 November 2021. CPT 22510, 22511, 22512, 22513, 22514, 22515. ICD-10 M80.08, M80.88, S22.000, S32.000, 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
Low back or thoracic pain due to a vertebral compression fracture
“low back or thoracic pain due to vertebral compression fractures” — p. 177
Confirmatory Diagnosis
Required
Imaging confirming the vertebral compression fracture and its underlying cause
“in order to stabilize vertebral fractures caused by osteoporosis, vertebral osteonecrosis, or malignancies of the spinal column.” — p. 177
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. 177
Procedures — the guideline treats each separately
Vertebroplasty as routine treatment — subacute or chronic vertebral compression fracture
Strongly Not Recommended. Vertebroplasty is strongly not recommended as a routine treatment for patients with low back or thoracic pain due to vertebral compression fractures.
Strength of Evidence — Strongly Not Recommended, Evidence (A) [Subacute, Chronic] · confidence high · p. 177
Indications — required:
The guideline strongly advises against routine vertebroplasty in subacute and chronic presentations
“Vertebroplasty is strongly not recommended as a routine treatment for patients with low back or thoracic pain due to vertebral compression fractures.” — p. 177
Strongly NOT recommended at High confidence — the strongest negative position this chapter takes on any operation. Routine vertebroplasty for a subacute or chronic compression fracture will not be supported by the MTUS.
Vertebroplasty as routine treatment — acute vertebral compression fracture
Not Recommended. Strength of Evidence – Not Recommended, Evidence (C) [Acute]
Strength of Evidence — Not Recommended, Evidence (C) [Acute] · confidence moderate · p. 177
Indications — required:
The guideline advises against routine vertebroplasty in acute presentations, at a lower grade than for subacute and chronic
“Strength of Evidence – Not Recommended, Evidence (C) [Acute]” — p. 177
Not recommended, but at a lower grade and confidence than the subacute and chronic case. Still a negative finding; state the timing of the fracture so the correct grade is applied.
Vertebroplasty for highly select patients with unusual vertebral compression fractures
No Recommendation. There is no recommendation for or against the use of vertebroplasty for treatment of highly select patients with low back or thoracic pain due to unusual vertebral compression fractures.
Strength of Evidence — No Recommendation, Insufficient Evidence (I) · confidence low · p. 177
Indications — any one of the following:
Fracture despite bisphosphonate therapy
“These include patients who have had fractures despite bisphosphonate therapy” — p. 177
OR
Pathologic fracture due to neoplasm in the vertebral body
“pathologic fractures due to neoplasms in the vertebral body” — p. 177
OR
Multiple simultaneous compression fractures (three or more) — at least 3
“or multiple simultaneous compression fractures (three or more)” — p. 177
The guideline makes NO recommendation either way for this narrow group, and unlike most No Recommendation findings it publishes indications. Meeting them does not make the procedure recommended — it places the request in the group the guideline declines to rule on.
Kyphoplasty for low back or thoracic pain due to vertebral compression fractures
No Recommendation. There is no recommendation for or against the use of kyphoplasty for the treatment of low back or thoracic pain due to vertebral compression fractures.
Strength of Evidence — No Recommendation, Insufficient Evidence (I) · confidence low · p. 178
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 also be candidates.” — p. 178
No recommendation for or against. The guideline lists indications but sets no duration and no failed-treatment requirement, unlike the vertebroplasty select-patient path.