CurrentevicorePolicy CMM-607

Primary Vertebral — Percutaneous Vertebral Augmentation and Sacroplasty

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This policy governs medical necessity review for percutaneous vertebral augmentation procedures (vertebroplasty, kyphoplasty, sacroplasty) for primary vertebral conditions and applies to health benefit plans administered by Cigna/EviCore.

Policy Summary

Payerevicore

PolicyPrimary Vertebral — Percutaneous Vertebral Augmentation and Sacroplasty

Policy CodePolicy CMM-607

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionObtain prior authorization per CMM-600.1 and document concordant imaging, symptoms, treated levels, and prior conservative care when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤2Max levels same date

T5-L5Treated spine levels

7Codes listed

v1.0.2026Version

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CurrentevicorePolicy CMM-607

Primary Vertebral — Percutaneous Vertebral Augmentation and Sacroplasty

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Policy Summary

Payerevicore

PolicyPrimary Vertebral — Percutaneous Vertebral Augmentation and Sacroplasty

Policy CodePolicy CMM-607

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionObtain prior authorization per CMM-600.1 and document concordant imaging, symptoms, treated levels, and prior conservative care when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤2Max levels same date

T5-L5Treated spine levels

7Codes listed

v1.0.2026Version

Coverage Criteria

Medically necessary indications (overview)

Vertebral augmentation is considered medically necessary for ANY of the following when ALL of the associated criteria have been met:

Top-level indication groups

Associated Surgical Procedure: Performed as a prophylactic vertebroplasty (including adjacent vertebrae if needed) to facilitate fusion surgery; performed at no more than two (2) levels of the T5-L5 spine on the same date of service.<= 2 levels; T5-L5
[[chunk 18]]
Malignant Conditions: Imaging is concordant with the individual's symptoms and physical exam findings and shows either osteolytic metastases including destruction of a vertebral body by multiple myeloma or primary malignant neoplasm of bone or bone marrow; symptoms include significant daily pain causing clinically significant functional impairment.
[[chunk 19]]
Non-Malignant Conditions: Imaging is concordant with the individual's symptoms and physical exam findings and meets the non-malignant criteria (see Non-malignant Conditions block).
[[chunk 20]]

Associated Surgical Procedure (see below): Refer to Associated Surgical Procedure criteria for required elements

Chunk 18 contains full criteria

Malignant Conditions (see below): Refer to Malignant Conditions criteria for required elements

Chunk 19 contains full criteria

Non-Malignant Conditions (see below): Refer to Non-Malignant Conditions criteria for required elements

Chunk 20 contains full criteria

Associated surgical procedure

Associated surgical procedure — covered when ALL of the following are met:

Associated surgical procedure: Performed as a prophylactic vertebroplasty (including adjacent vertebrae if needed) to facilitate fusion surgery.

Spinal levels and count: Performed at no more than two (2) levels of the T5-L5 spine on the same date of service.<= 2 levels; T5-L5

Malignant conditions

Malignant conditions — covered when ALL of the following are met:

Imaging concordant with symptoms: Imaging is concordant with the individual's symptoms and physical exam findings.

Malignant disease on imaging: Imaging shows EITHER osteolytic metastases including destruction of a vertebral body by multiple myeloma OR primary malignant neoplasm of bone or bone marrow.

Symptom severity: Symptoms include a significant level of pain on a daily basis defined as clinically significant functional impairment (e.g., inability to perform household chores, prolonged standing).

Non-malignant conditions

Non-malignant conditions — covered when ALL of the following are met:

Imaging concordant with symptoms: Imaging is concordant with the individual's symptoms and physical exam findings and shows ANY of the following: osteoporotic vertebral compression fracture; osteolytic vertebral compression fracture; aggressive space-occupying lesion of a vertebral body (e.g., hemangioma or eosinophilic granuloma); osteonecrotic vertebral compression fracture (Kummel disease); or steroid-induced vertebral compression fracture.

Spinal levels and count: Performed at no more than two (2) levels of the T5-L5 spine on the same date of service.<= 2 levels; T5-L5

Pain timeframe and response:

This coverage policy applies to health benefit plans administered by Cigna and is intended to guide medical necessity determinations for percutaneous vertebral augmentation procedures. In the event of any conflict between this coverage policy and a customer's particular benefit plan document, the customer's benefit plan document supersedes the coverage policy. Coverage determinations also require consideration of applicable laws/regulations, relevant collateral materials, and the specific facts of each case. (See CMM-600.1 for additional timing and documentation requirements.)

Per the policy, sacroplasty and coccygeoplasty are considered not medically necessary. These procedures—percutaneous injection techniques applied to the sacrum or coccyx—are not covered under the indications for vertebral augmentation set forth in this document.

Primary vertebral augmentation (percutaneous vertebroplasty/kyphoplasty) is considered not medically necessary for a number of specified situations. Examples include treatment of non‑painful or non‑aggressive vertebral hemangioma, any vertebra of the cervical spine at any level, and thoracic vertebrae at levels T1–T4. The policy also lists other primary procedure exclusions such as prophylactic treatment for osteoporosis or chronic longstanding back pain (>6 months).

The reference section of this policy includes bibliographic citations and safety literature. Among these references is material related to complications and outcomes after vertebral augmentation procedures; the document cites systematic and technology assessment reports that discuss risks associated with bone cement and augmentation techniques.

Within the pages extracted for this section there are no additional explicit items listed as not medically necessary beyond those already stated in the Not Medically Necessary and contraindications sections of the policy.

Vertebral augmentation performed without meeting the policy's General Guidelines and the applicable procedure‑specific indications is considered not medically necessary and may be denied. The policy also highlights common alternative causes of axial back pain (e.g., radiculopathy, facet disease, sacral/coccyx lesions) and lists contraindications—such as allergy to procedure materials, uncorrected coagulation disorders, active infection, extensive vertebral destruction, burst fractures with retropulsed fragments, or unstable fractures—that should be evaluated before authorization.

Coding

Listed Procedure CodesCPT | HCPCS

22510	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
22511	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral
+22512	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (list separately)
22513	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., 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 (e.g., kyphoplasty); 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar
+22515	Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty); each additional thoracic or lumbar vertebral body (list separately)
0201T	Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device when used, two or more needles, includes imaging guidance and bone biopsy when performed

No CPT/HCPCS/ICD codes in this excerptmixed

No codes listed

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior authorization required per CMM-600.1

Prior authorization and documentation rules apply; see CMM-600.1 for specific timing and documentation requirements before requesting vertebral augmentation or sacroplasty.

Follow CMM-600.1: Prior Authorization Requirements for submission timing and required supporting materials.

Prior Authorization

Prior authorization for listed procedure codes

Requests for the CPT/HCPCS codes listed in the policy (22510, 22511, +22512, 22513, 22514, +22515, 0201T) are subject to prior authorization per the plan; inclusion in the code table does not itself guarantee payment.

Codes subject to authorization: 22510, 22511, +22512, 22513, 22514, +22515, 0201T

Prior Authorization

Background

Vertebral augmentation (vertebroplasty and kyphoplasty) refers to a group of minimally invasive procedures that stabilize and, in some techniques, restore vertebral body height through percutaneous placement of polymethylmethacrylate (PMMA) bone cement and use of devices (for example, balloon kyphoplasty or mechanical implant systems). These techniques are used to treat painful or pathologic vertebral compression fractures and may include balloon kyphoplasty, mechanical kyphoplasty (e.g., expandable implants, stents), and vertebroplasty.

Definitions

Definition — Vertebral augmentation (procedure description key/value)

TermVertebral augmentation

DescriptionA minimally invasive procedure for stabilization and restoration of a vertebra to treat painful, pathologic fractures; includes vertebroplasty and kyphoplasty techniques; when applied to sacrum/coccyx termed sacroplasty/coccygeoplasty.

Common techniquesVertebroplasty, balloon kyphoplasty, mechanical kyphoplasty (e.g., Kiva, SpineJack, StabiliT), and sacroplasty/coccygeoplasty.

Definition — Balloon kyphoplasty

TermBalloon kyphoplasty

DescriptionA percutaneous kyphoplasty technique that involves the use of a specialized balloon to expand collapsed vertebrae, which then allows injection of PMMA cement.

Policy Summary

Payerevicore

PolicyPrimary Vertebral — Percutaneous Vertebral Augmentation and Sacroplasty

Policy CodePolicy CMM-607

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionObtain prior authorization per CMM-600.1 and document concordant imaging, symptoms, treated levels, and prior conservative care when required.

SourceLink

On This Page

Either: (A) acute (0-6 weeks) axial pain in the thoracic/lumbar spine that prevents independent transfers or ambulation and correlates with the fracture level; OR (B) subacute (> 6 weeks) axial pain with less than clinically meaningful improvement after BOTH: 4 weeks of prescription-strength analgesics/steroids/NSAIDs AND a 4-week provider-directed exercise program (unless contraindicated).

acute = 0-6 weeks; subacute >6 weeks with required conservative measures

For osteoporotic compression fractures, enrollment in an osteoporosis treatment and prevention program is required.

Prior authorization details not specified on these pages

The extracted bibliographic pages do not provide an expanded list of authorization-specific procedural requirements beyond referencing CMM-600.1; follow the plan’s prior authorization process for affected codes.

Step Therapy

Urgent/emergent exception to conservative management

For confirmed urgent/emergent conditions (e.g., pathologic fracture from primary or metastatic neoplastic disease, or incapacitating pain causing severe dysfunction), provider-directed non-surgical management is not required prior to vertebral augmentation.

Urgent/emergent indications include: primary or metastatic neoplastic disease causing pathologic fracture, or severe debilitating/incapacitating pain with documented dysfunction.
Provider-directed non-surgical management is NOT required for confirmed urgent/emergent conditions.

Step Therapy

Conservative therapy requirement for subacute non-malignant fractures

For subacute (>6 weeks) non-malignant vertebral compression fractures, document that the individual had BOTH at least 4 weeks of prescription-strength analgesics/steroids/NSAIDs and a 4-week provider-directed exercise program unless contraindicated.

Prescription-strength analgesics, steroids, and/or NSAIDs for four (4) weeks
Provider-directed exercise program (prescribed by PT, chiropractic provider, DO/MD) for four (4) weeks
If <=6 weeks and patient has acute (0–6 weeks) axial pain that prevents independent transfers or ambulation, conservative management requirement does not apply.

Note

No step therapy or sequencing requirements provided

No step therapy sequencing or additional treatment-sequencing requirements are specified in the extracted policy pages.

Documentation Required

Prior authorization documentation must follow CMM-600.1

Follow the timing and documentation requirements in CMM-600.1 when submitting prior authorization requests for vertebral augmentation or sacroplasty.

Include all materials required by CMM-600.1; timing and submission processes are defined there.

Documentation Required

Required clinical documentation to support medical necessity

Include concordant imaging and documented symptoms/physical exam findings; specify the vertebral level(s) to be treated and document significant daily pain causing functional impairment.

Imaging must be concordant with symptoms and physical exam.
Document level(s) treated and daily pain causing functional impairment (e.g., inability to perform household chores, prolonged standing).
For osteoporotic fractures, document enrollment in an osteoporosis treatment and prevention program when applicable.

Documentation Required

No additional documentation/prior authorization steps on these pages

The extracted reference section does not list additional documentation or prior authorization steps; rely on CMM-600.1 and the clinical documentation requirements in this policy when preparing requests.

Denial Risk

Basis for denial risk — case-by-case and plan-specific considerations

Coverage determinations are made case-by-case and must consider the applicable benefit plan, laws/regulations, collateral materials, and facts of the situation; failure to meet plan-specific requirements may result in denial.

Denial Risk

Denial risk for unmet medical necessity criteria

Requests that do not meet the General Guidelines and the procedure‑specific indications (associated surgical procedure, malignant, or non‑malignant conditions) are considered not medically necessary and may be denied.

Vertebral augmentation performed without meeting required indications is considered not medically necessary.

Denial Risk

Denial risk for procedures in presence of non‑indications or contraindications

Do not request or perform vertebral augmentation when applicable non‑indications or contraindications are present (e.g., uncorrected coagulation disorders/anticoagulation therapy, active infection, extensive vertebral destruction, burst fracture with retropulsed fragments); such cases are considered not medically necessary and are subject to denial.

Contraindications listed include allergy to procedure materials and uncorrected coagulation disorders or anticoagulation therapy.
Other not medically necessary situations: extensive vertebral destruction, burst fractures with widened pedicles/retropulsed fragments, active osteomyelitis or any active infection, unstable fractures needing stabilization.

Denial Risk

No additional authorization‑specific denial triggers listed here

No authorization-specific denial triggers (beyond the policy’s clinical criteria and referenced safety notices) are identified in these extracted pages.

PurposeRestore vertebral height and create a cavity for PMMA cement placement.

Definition — Mechanical kyphoplasty (Kiva, SpineJack, StabiliT, vertebral body stenting)

TermMechanical kyphoplasty (e.g., Kiva, SpineJack, StabiliT, vertebral body stenting)

DescriptionPercutaneous kyphoplasty techniques using a device other than a balloon to expand collapsed vertebrae (examples: Kiva VCF coil/PEEK implant, SpineJack expandable implant, StabiliT radiofrequency-modified cement delivery, vertebral body stents), followed by PMMA cement placement.

MechanismsIncludes coil/implant conduits (Kiva), expandable implants (SpineJack), radiofrequency-modified ultrahigh-viscosity cement systems (StabiliT), and metal stent devices to create a stent-reinforced cement implant.

Definition — Vertebroplasty

TermVertebroplasty

DescriptionA percutaneous vertebral augmentation procedure that involves image-guided injection of polymethylmethacrylate (PMMA) cement into a vertebral body to stabilize painful compression fractures.

DistinctionVertebroplasty typically involves direct cement injection without prior cavity creation with a balloon or mechanical implant.

Definition — Acute axial pain (0-6 weeks)

TermAcute axial pain (thoracic/lumbar)

Timeframe0-6 weeks from onset.

Clinical criteriaPain that persists at a level which prevents independent transfers or ambulation and correlates with the level of the fracture.

Definition — Subacute axial pain (>6 weeks)

TermSubacute axial pain (thoracic/lumbar)

Timeframe> 6 weeks from onset.

Conservative care requirementLess than clinically meaningful improvement after BOTH 4 weeks of prescription-strength analgesics/steroids/NSAIDs and a 4-week provider-directed exercise program (unless contraindicated).

Definition — vertebral augmentation term as used across references

Usage'Vertebral augmentation' as used across references includes percutaneous vertebroplasty, balloon kyphoplasty, and implantable vertebral augmentation systems (mechanical kyphoplasty/vertebral body stents).

ScopeTerm encompasses techniques that restore vertebral height and/or stabilize vertebral bodies using PMMA cement and adjunct devices.

SynonymsVertebroplasty, kyphoplasty, mechanical kyphoplasty, vertebral augmentation systems.

Definition — sacroplasty

TermSacroplasty

DescriptionPercutaneous injection of bone cement into sacral insufficiency fractures (sacroplasty); analogous technique to vertebroplasty applied to the sacrum, referenced in observational and pilot studies.

NoteSacroplasty and coccygeoplasty are discussed separately and are considered not medically necessary in this policy excerpt.