CurrentBaylor Scott & White Health PlanPolicy 084

Vertebroplasty, Kyphoplasty and Sacroplasty

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Medical-necessity review and prior authorization for percutaneous vertebroplasty, balloon-assisted vertebroplasty/kyphoplasty, sacroplasty, and related procedures across lines of business, with plan-specific review pathways.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyVertebroplasty, Kyphoplasty and Sacroplasty

Policy CodePolicy 084

Change TypeMaterial clinical and coverage revision

Effective DateAug 1, 2026

Last ReviewJul 23, 2026

Next Review DateJul 23, 2027

Key ActionSubmit prior authorization for vertebroplasty, kyphoplasty, sacroplasty, and related procedures.

SourceLink

POLICY UPDATE CHANGES

Added case-by-case medical-necessity criteria for sacroplasty based on documented sacral insufficiency fracture, persistent pain, pain attribution, and failure or ineligibility for other treatments.

Updated the background section to describe current treatment timing and evidence for vertebroplasty and kyphoplasty and to include recent sacroplasty evidence.

Changed the service title to include the word “and” in “Vertebroplasty, Kyphoplasty and Sacroplasty.”

RequiredPrior authorization

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CurrentBaylor Scott & White Health PlanPolicy 084

Vertebroplasty, Kyphoplasty and Sacroplasty

Customize your policy alerts

Sign up for baylor_scott_and_white_health_plan Policy 084 alerts

Get alerted when Policy 084 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerBaylor Scott & White Health Plan

PolicyVertebroplasty, Kyphoplasty and Sacroplasty

Policy CodePolicy 084

Change TypeMaterial clinical and coverage revision

Effective DateAug 1, 2026

Last ReviewJul 23, 2026

Next Review DateJul 23, 2027

Key ActionSubmit prior authorization for vertebroplasty, kyphoplasty, sacroplasty, and related procedures.

SourceLink

POLICY UPDATE CHANGES

Added case-by-case medical-necessity criteria for sacroplasty based on documented sacral insufficiency fracture, persistent pain, pain attribution, and failure or ineligibility for other treatments.

Updated the background section to describe current treatment timing and evidence for vertebroplasty and kyphoplasty and to include recent sacroplasty evidence.

Changed the service title to include the word “and” in “Vertebroplasty, Kyphoplasty and Sacroplasty.”

RequiredPrior authorization

≥ 5Minimum pain rating for sacroplasty

4 weeksConservative management duration

30%–70%Reported cement-leakage rate

NoneMandates identified

Medical Necessity Criteria

Sacroplasty medical necessity

Sacroplasty may be considered medically necessary on a case-by-case basis when ALL of the following are met:

Sacroplasty criteria

Imaging-confirmed fracture: Documented sacral insufficiency fracture confirmed by CT or MRICT or MRI confirmation
Persistent refractory pain: Sustained moderate to severe pain refractory to conservative managementNumerical Rating System ≥ 5; conservative management for at least 4 weeks
Pain attribution: Pain is attributable to the sacral fracture and not to other causes
Other-treatment status: The patient is not a candidate for, or has failed, other treatments

CPT 0200T and 0201T, which describe percutaneous sacral augmentation (sacroplasty), are listed in the policy’s CPT Not Covered section.

Coding Reference

CPT CodesCPT

22510	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance
22511	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance
22512	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional
22513	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic
22514	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance
22515	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance
22899	Spine surgery procedure

CPT Not CoveredCPTNot Covered

0200T	Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device
0201T	Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of

ICD10 CodesICD-10

M80.88x	Osteoporosis with pathologic fracture, vertebrae
M48.54X	Collapsed vertebra
M48.55x	Collapsed vertebra
M48.56x	Collapsed vertebra
S22.000x	Thoracic vertebrae wedge fracture
S22.010x	Thoracic vertebrae wedge fracture
S22.020x	Thoracic vertebrae wedge fracture
S22.030x	Thoracic vertebrae wedge fracture
S22.040x	Thoracic vertebrae wedge fracture
S22.050x	Thoracic vertebrae wedge fracture

1–10 of 17

1/2

Sacroplasty Pain Threshold

Minimum pain scoreNumerical Rating System ≥ 5

Refractory Conservative Management

Minimum durationAt least 4 weeks of conservative management

Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for vertebroplasty, balloon-assisted percutaneous vertebroplasty, kyphoplasty, sacroplasty, and related procedures. For all plans except Medicaid and select self-funded plans, medical-necessity determinations for percutaneous vertebroplasty, balloon-assisted percutaneous vertebroplasty, kyphoplasty, and related procedures are made by eviCore®.

Submit the authorization request before performing the applicable service.
Medicaid plans and select self-funded plans may follow different review pathways as specified below.

Note

Medicare Review Pathway

For Medicare plans, review the applicable Medicare coverage criteria before submitting the request. Use Medicare LCD L35130, Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); if no applicable NCD or LCD criteria exist, use the criteria in this policy.

Confirm whether an applicable Medicare NCD or LCD governs the service.

Clinical Background

Percutaneous vertebroplasty involves injecting bone cement into a cervical, thoracic, or lumbar vertebral body to relieve pain and strengthen bone affected by a painful vertebral compression fracture. Kyphoplasty, also called balloon-assisted vertebroplasty, uses an inflatable balloon tamp to expand the collapsed vertebra before cement injection. Conservative treatment may include physical therapy, bed rest, bracing, and analgesics; many symptomatic vertebral compression fractures improve within 4 to 6 weeks.

Evidence has not established a proven advantage of kyphoplasty over vertebroplasty. Sacroplasty is a percutaneous treatment for sacral insufficiency fracture and is supported by limited but growing evidence; consideration is case by case when the policy’s medical-necessity requirements are met, including imaging confirmation, persistent moderate-to-severe pain, failure or ineligibility for other treatments, and attribution of pain to the sacral fracture.

Procedure Definitions

Percutaneous Vertebroplasty

ProcedureA minimally invasive procedure involving injection of bone cement, usually polymethylmethacrylate, into an affected cervical, thoracic, or lumbar vertebral body for pain relief and bone strengthening.

Kyphoplasty

ProcedureAn adaptation of vertebroplasty that expands the collapsed vertebra with an inflatable balloon tamp before injection of bone cement.

Sacroplasty

ProcedurePercutaneous treatment for a documented sacral insufficiency fracture, considered medically necessary on a case-by-case basis when specified criteria are met.

Evidence contextSacroplasty has limited but growing evidence and remains under active evidence review.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyVertebroplasty, Kyphoplasty and Sacroplasty

Policy CodePolicy 084

Change TypeMaterial clinical and coverage revision

Effective DateAug 1, 2026

Last ReviewJul 23, 2026

Next Review DateJul 23, 2027

Key ActionSubmit prior authorization for vertebroplasty, kyphoplasty, sacroplasty, and related procedures.

SourceLink

On This Page

Document the criteria used when the fallback policy criteria are applied.

Note

Medicaid Review Pathway

For Medicaid plans, confirm coverage and medical necessity under the Texas Medicaid Provider Procedures Manual (TMPPM), administered through TMHP. If the TMPPM contains no applicable criteria, use the criteria in this policy.

Verify the current Texas Medicaid manual requirements.
Document the fallback policy criteria when no applicable TMPPM criteria guide the determination.

Documentation Required

Sacroplasty Medical-Necessity Documentation

Sacroplasty may be considered medically necessary on a case-by-case basis only when the required clinical documentation supports all listed criteria. The service remains under active evidence review.

Document a sacral insufficiency fracture confirmed by CT or MRI.
Document sustained moderate-to-severe pain with a Numerical Rating System score of ≥ 5 that is refractory to conservative management for at least 4 weeks.
Document that the pain is attributable to the sacral fracture and not to another cause.
Document that the patient is not a candidate for, or has failed, other treatments.

Note

Review the Applicable Benefit Plan

Review the member-specific Evidence of Coverage (EOC) or Summary Plan Description (SPD) for coverage details before concluding that a service is payable.

The applicable benefit-plan document governs coverage, exclusions, limitations, and conditions of coverage.

Denial Risk

Sacroplasty Criteria Not Met

Sacroplasty does not meet policy criteria when any required element is absent or cannot be substantiated. Requests may be denied when imaging confirmation, qualifying pain and duration, attribution of pain to the fracture, or documentation regarding other treatments is missing.

No CT or MRI confirmation of a sacral insufficiency fracture.
Pain is below the Numerical Rating System threshold of 5 or has not been refractory to conservative management for at least 4 weeks.
Pain is attributable to another condition rather than the sacral fracture.
The patient is a candidate for, and has not failed, other treatments.
Sacroplasty remains subject to ongoing evidence review.

Billing Rule

Sacroplasty Codes Listed as Not Covered

Do not submit CPT 0200T or 0201T as covered sacroplasty services under this policy. These sacroplasty codes are listed as not covered.

0200T — Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including use of a balloon or mechanical device.
0201T — Percutaneous sacral augmentation (sacroplasty), bilateral injections, including use of a balloon or mechanical device when used, involving two or more needles.

Note

Benefit-Plan Limitations

Medical necessity under this policy does not guarantee reimbursement. Benefits are ultimately determined by the applicable benefit-plan document, and federal or state rules and regulations may also control coverage.

The plan document supersedes this policy in the event of a discrepancy.
Confirm member-specific exclusions, limitations, and conditions of coverage.