CurrentBaylor Scott & White Health PlanPolicy 084

Vertebroplasty, Kyphoplasty and Sacroplasty

Defines medical necessity, prior authorization, coding and coverage stance for percutaneous vertebroplasty, balloon-assisted vertebroplasty (kyphoplasty) and sacroplasty for Baylor Scott & White Health Plan members across applicable lines of business.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyVertebroplasty, Kyphoplasty and Sacroplasty

Policy CodePolicy 084

Change TypeMaterial updates — sacroplasty non-coveredcoding list updated

Effective DateSep 1, 2025

Next Review DateJun 9, 2026

Key ActionObtain prior authorization for vertebroplasty or kyphoplasty; sacroplasty is non-covered and will be denied.

SourceLink

POLICY UPDATE CHANGES

BSWHP considers sacroplasty experimental, investigational and unproven, and therefore NOT considered medically necessary for all lines of business.

Removed statement that 'Medicare NCD or LCD specific InterQual criteria may be used when available'.

Prior Auth Reqauthorization requirement

Not Medically Necessarysacroplasty stance

22510–22515CPT range listed

0200T–0201Tsacroplasty CPTs

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Coverage Criteria

Vertebroplasty / Kyphoplasty Medical Necessity

Covered when ALL of the following are met (per policy and when prior authorization is obtained):

General coverage conditions: Patient has a symptomatic vertebral compression fracture; conservative therapy (e.g., physical therapy, bed rest, bracing, analgesics) has been tried for an appropriate period (unless inappropriate) or the clinical situation warrants earlier intervention; the requested procedure is percutaneous vertebroplasty or kyphoplasty as defined in this policy; prior authorization has been obtained per the plan (eviCore manages determinations for most plans); medical necessity determination is consistent with the plan EOC/SPD and, when applicable, relevant Medicare LCD or TMPPM guidance.

Based on policy background and prior authorization requirements

BSW Health Plan considers sacroplasty to be experimental, investigational and unproven and therefore NOT medically necessary for all lines of business. This stance applies to percutaneous sacral augmentation procedures described in the policy and to CPT codes 0200T and 0201T, which are listed as non-covered. Providers should refer to the member’s Evidence of Coverage/Summary Plan Description for plan-specific benefit details and limitations.

Percutaneous sacroplasty (percutaneous sacral augmentation) is considered not medically necessary (experimental/investigational) for all lines of business and will be denied as such. Prior authorization processes do not render sacroplasty medically necessary when it is excluded by this policy.

Coding

Procedure CPT CodesCPT

22510	Percutaneous vertebroplasty (bone biopsy included when performed), 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
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 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 a balloon or mechanical device, when used, 2 or more needles

Example ICD-10 CodesICD-10

M80.88x	Osteoporosis with pathologic fracture, vertebrae
M48.54x	Collapsed vertebra
M48.55x	Collapsed vertebra
M48.56x	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
S22.060x	Thoracic vertebrae wedge fracture

1–10 of 17

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Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for percutaneous vertebroplasty, balloon-assisted percutaneous vertebroplasty, kyphoplasty, and any related procedures. Sacroplasty is considered experimental, investigational and unproven and is NOT covered for all lines of business; authorization requests for sacroplasty should be denied.

Prior authorization required for vertebroplasty, balloon-assisted vertebroplasty, kyphoplasty, and related procedures
Sacroplasty is considered experimental/investigational and NOT covered — do not authorize

Note

Conservative Care Expectation

Conservative therapy should be attempted or documented as considered prior to performing vertebroplasty or kyphoplasty unless clinical circumstances justify proceeding sooner. Examples of conservative care include physical therapy, bed rest, bracing, and analgesics. Note that approximately two-thirds of patients with symptomatic vertebral compression fractures improve after 4–6 weeks of conservative treatment; document the trial and response.

Document trial of conservative care (e.g., physical therapy, bracing, bed rest, analgesics) prior to procedure unless clinically contraindicated

Background

Percutaneous vertebroplasty and kyphoplasty are minimally invasive procedures intended to relieve pain and stabilize or restore height of a collapsed vertebral body by the injection of bone cement (commonly polymethylmethacrylate). Kyphoplasty is a balloon-assisted variant in which an inflatable balloon tamp is used to restore vertebral height prior to cement augmentation. These procedures are offered when conservative management (for example, physical therapy, bracing, bed rest, analgesics) has failed or is inappropriate and when prior authorization requirements are met.

Definitions

Percutaneous vertebroplasty — definition & summary

DefinitionInjection of bone cement (usually polymethylmethacrylate) into a cervical, thoracic or lumbar vertebral body to relieve pain and strengthen bone.

Typical indicationSymptomatic vertebral compression fracture causing pain after conservative therapy or when conservative care is inappropriate.

Key risksCement leakage (reported in 30%–70% of cases; most are asymptomatic) and possible adjacent-level vertebral fractures.

Kyphoplasty (balloon-assisted vertebroplasty) — definition & summary

DefinitionBalloon-assisted percutaneous vertebroplasty (kyphoplasty) that uses an inflatable balloon tamp to expand the collapsed vertebra prior to cement injection to help restore vertebral height and reduce kyphotic deformity.

Relation to vertebroplasty

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyVertebroplasty, Kyphoplasty and Sacroplasty

Policy CodePolicy 084

Change TypeMaterial updates — sacroplasty non-coveredcoding list updated

Effective DateSep 1, 2025

Next Review DateJun 9, 2026

Key ActionObtain prior authorization for vertebroplasty or kyphoplasty; sacroplasty is non-covered and will be denied.

SourceLink

On This Page

If proceeding without a documented trial, provide justification in clinical records explaining why conservative management was not appropriate or feasible

Documentation Required

Required Documentation

Providers must submit documentation to support medical necessity when requesting prior authorization. Incomplete or missing documentation may result in denial. Required documentation includes patient clinical history, relevant imaging, treatment records showing conservative care trial or rationale for foregoing it, and procedure-specific notes. For Medicare and Medicaid lines of business, reference any applicable LCD/NCD or state manual criteria in the authorization submission when available.

Clinical notes detailing symptoms, neurologic findings, and duration of symptoms
Imaging reports and images (e.g., recent spinal radiographs, CT or MRI demonstrating vertebral compression fracture and correlating level)
Documented trial of conservative management (dates, modalities used, and response) or clinical rationale for immediate intervention
Operative/procedural notes and informed consent if procedure already performed
Reference to plan EOC/SPD, Medicare LCD/NCD (if applicable), or Texas Medicaid Provider Procedures Manual when relevant

Denial Risk

Denial Triggers

Failure to obtain prior authorization, lack of required documentation, or request for sacroplasty may lead to denial. Requests that do not demonstrate a trial of conservative care (or an acceptable clinical justification for proceeding without one), lack correlating imaging, or do not meet referenced LCD/state criteria should be denied. Providers should confirm member benefits in the plan's EOC/SPD because medical necessity per this policy does not guarantee coverage.

Denial likely if prior authorization is not obtained before the procedure
Denial likely for sacroplasty — considered experimental/investigational and not medically necessary
Denial may occur if documentation lacks imaging that correlates with the treated level or lacks evidence of conservative care trial or justification
Denial may occur if request does not meet applicable Medicare LCD, NCD, or state Medicaid criteria where applicable
Medical necessity determination in this policy does not assure benefit coverage; verify member plan EOC/SPD

An adaptation of vertebroplasty; includes cavity creation with a balloon prior to polymethylmethacrylate injection.

Evidence noteNo proven advantages of kyphoplasty over vertebroplasty regarding pain relief, height restoration, or complication rate; benefits in specific subgroups remain undefined.

Sacroplasty — definition & coverage note

DefinitionPercutaneous sacral augmentation (sacroplasty).

Policy coverage stanceConsidered experimental, investigational and unproven and NOT medically necessary for all lines of business; CPT codes 0200T and 0201T are listed as non‑covered.

Evidence noteNo quality randomized controlled trials; limited literature with uncertainty regarding impact on pain and other health outcomes; harms not adequately studied.