ModifiedProvidence Health PlanPolicy 342

Percutaneous Vertebroplasty and Sacroplasty

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Medicare medical policy governing percutaneous vertebral augmentation (vertebroplasty, kyphoplasty) and percutaneous sacral augmentation (sacroplasty) for Providence Health Plan Medicare members; describes coverage framework, definitions, background, and applicability when Medicare coverage criteria are not fully established.

Policy Summary

PayerProvidence Health Plan

PolicyPercutaneous Vertebroplasty and Sacroplasty

Policy CodePolicy 342

Change TypeMaterial coverage revisions and coding clarifications

Effective DateJun 1, 2026

Last ReviewNov 11, 2025

Next Review DateSep 1, 2026

Key ActionWhen Medicare coverage criteria are not fully established for PVA indications, follow the plan's internal criteria or referenced LCDs and obtain prior authorization for unlisted codes to avoid post-service denials.

SourceLink

POLICY UPDATE CHANGES

Coverage for PVA related to trauma and malignancy has been reinstated based on review of comments and supporting data.

Language updated to distinguish between osteoporotic versus traumatic vertebral compression fractures.

Updated language regarding sacroplasty procedures and associated CPT/HCPCS code guidance.

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ModifiedProvidence Health PlanPolicy 342

Percutaneous Vertebroplasty and Sacroplasty

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Policy Summary

PayerProvidence Health Plan

PolicyPercutaneous Vertebroplasty and Sacroplasty

Policy CodePolicy 342

Change TypeMaterial coverage revisions and coding clarifications

Effective DateJun 1, 2026

Last ReviewNov 11, 2025

Next Review DateSep 1, 2026

SourceLink

POLICY UPDATE CHANGES

Coverage for PVA related to trauma and malignancy has been reinstated based on review of comments and supporting data.

Language updated to distinguish between osteoporotic versus traumatic vertebral compression fractures.

Updated language regarding sacroplasty procedures and associated CPT/HCPCS code guidance.

Medicare Onlyproduct/benefit application

342policy identifier

ReinstatedPVA trauma/malignancy

6/1/2026effective

Noridian & WPSLCAs cited

Coverage Criteria for Percutaneous Vertebral & Sacral Augmentation

Use of internal or MAC LCD criteria for PVA indications

When Medicare coverage criteria are not fully established for a percutaneous vertebral augmentation (PVA) indication, the plan will apply internal criteria or adopt LCD criteria from a Medicare contractor to determine coverage.

Adoption of criteria: When Medicare coverage criteria are not fully established for a PVA indication, the plan may use publicly accessible internal coverage criteria based on current evidence or adopt Local Coverage Determination (LCD) criteria from a Medicare Administrative Contractor (MAC) to determine coverage.

Internal criteria are based on current guidelines and evidence; when adopting LCDs, the plan may use criteria from a MAC such as WPS or Noridian as described in this policy.

Sacroplasty coverage stance

Company position for percutaneous sacral augmentation (sacroplasty) in Medicare members.

Sacroplasty not medically necessary: Percutaneous sacral augmentation (sacroplasty), with or without cavity creation (CPT 0200T, 0201T, or CPT 22511), is considered not medically necessary for Medicare under Company medical policy.

See Policy Guidelines and coding sections for additional context and billing guidance.

Traumatic and Malignant-Related VCF Coverage

Coverage for PVA related to trauma and malignancy is allowed when the referenced LCD criteria are met; this follows reinstated LCD language and the plan's adoption of MAC criteria where applicable.

Traumatic/Malignant VCF coverage reinstated: Coverage for PVA performed for vertebral compression fractures related to trauma or malignancy has been reinstated per review of comments and supporting data; providers must follow the referenced LCD/LCA criteria for specific clinical indications and documentation requirements.

See associated LCAs (e.g., WPS) and the policy revision history for details on reinstatement and applicable criteria. When local Medicare guidance is not established for traumatic VCFs, the plan adopts WPS LCD criteria as described in this policy.

Percutaneous sacral augmentation (sacroplasty), whether performed with cavity creation (CPT 0200T, 0201T) or without cavity creation (CPT 22511), is an explicit exclusion for Medicare members under this Company medical policy. The procedure is considered not medically necessary for Medicare and may be denied when billed for Medicare beneficiaries; providers should review the member EOC and policy guidelines before submitting claims.

All unlisted codes are reviewed at the claim level for medical necessity, coding accuracy, and pricing. If an unlisted code is submitted for a service that is non-covered under this policy, it will be denied as not covered. For unlisted codes that may represent potentially covered services, prior authorization is recommended to avoid post-service denial.

As stated in the Company Medicare medical policy, percutaneous sacral augmentation (sacroplasty) is considered not medically necessary for Medicare. Services excluded by Medicare or the member's evidence of coverage may be denied; consult the policy guidelines and member benefit documents for applicability to individual cases.

Prior revisions to this policy replaced the term 'investigational' with 'not medically necessary' for certain scenarios. The policy history and revision notes direct providers to review the referenced local coverage determinations and companion LCAs for specifics when determining not medically necessary (NMN) status for a given service or indication.

Billing and Coding Guidance

Sacroplasty CPT codes referencedCPTNot Covered

0200T	Percutaneous sacral augmentation with cavity creation (as listed)
0201T	Percutaneous sacral augmentation with cavity creation (as listed)
22511	Percutaneous sacral augmentation without cavity creation (as listed)

Covered CPT/HCPCS CodesmixedCovered

0200T	Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, 1 or more needles, includes imaging guidance and bone biopsy, when performed.
0201T	Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, 2 or more needles, includes imaging guidance and bone biopsy, when performed.
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 (also used for sacroplasty without mechanical device).
22512	Percutaneous vertebroplasty, each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure).
22513	Percutaneous vertebral augmentation including cavity creation using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; addition to code for primary procedure.
22514	Percutaneous vertebral augmentation (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic.
22515	Percutaneous vertebral augmentation (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar.
C1062	Intravertebral body fracture augmentation with implant (e.g., metal, polymer).
C7504	Percutaneous vertebroplasties (bone biopsies included when performed), first cervicothoracic and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusive of all imaging guidance.

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NCCI / MUE edits - coding and claim review

NCCI / MUE editsSubject to NCCI procedure-to-procedure bundling edits and daily MUE (medically unlikely edits) published by CMS; this policy does not override NCCI/MUEs — consult CMS for applicable code combinations.

Claim-level reviewAll unlisted and listed codes are reviewed for medical necessity, correct coding, and pricing at the claim level.

Prior authorization for unlisted codesIf an unlisted code is submitted for potentially covered services, prior authorization is recommended to avoid post-service denial.

No implied coverage by MPFS listingPresence of a payment in the Medicare Physician Fee Schedule or issuance of a CPT/HCPCS code does not imply Medicare coverage or medical necessity.

Reference guidanceRefer to CMS resources (NCCI edits, MUEs, MPFSDB) and the plan’s reimbursement/policy pages for coding guidance and applicable edits.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Apply internal or MAC LCD criteria when Medicare criteria are not established

When Medicare coverage criteria for a PVA indication are not fully established in applicable Medicare statutes, regulations, NCDs or LCDs, the plan may apply internal, publicly accessible coverage criteria or adopt LCD criteria from a Medicare contractor (MAC) to determine coverage; providers should follow the plan’s utilization management processes (e.g., pre-service review) and the referenced LCD criteria where applicable.

Plan may use internal coverage criteria based on current evidence when Medicare criteria are not fully established.
Plan may adopt LCD criteria from a MAC (for example, WPS criteria for traumatic VCFs) as permitted by CMS guidance.

Prior Authorization

Recommend prior authorization for unlisted codes

For unlisted procedure codes submitted for potentially covered services, prior authorization is recommended to avoid post-service denial; consult the referenced LCAs and the plan’s prior authorization processes for additional guidance.

Background and Rationale

Osteoporosis is a common systemic skeletal disorder characterized by reduced bone mass and microarchitectural deterioration, which increases susceptibility to fracture. Vertebral compression fractures (VCFs) occur both from low-energy (fragility) events associated with osteoporosis and from high-energy traumatic injuries; malignant involvement of the vertebrae is another recognized etiology. Management options range from conservative measures (analgesics, activity modification, bracing, osteoporosis therapy, and rehabilitation) to image-guided percutaneous vertebral augmentation (vertebroplasty/kyphoplasty) aimed at stabilizing the fracture, reducing pain, and potentially restoring alignment. Certain fracture patterns (for example, severe vertebral body collapse or unstable fractures) and device or cement-related contraindications may preclude PVA.

Definitions and Procedural Terms

VCF — Vertebral compression fracture definition

DefinitionVertebral compression fracture (VCF): a fracture of a vertebral body characterized by collapse or compression of the vertebral body.

EtiologyCan result from low-energy (osteoporotic/fragility) events or high-energy trauma; also may be related to malignancy.

Clinical relevanceVCFs are a common consequence of osteoporosis and may cause pain, deformity, and functional limitation that inform treatment decisions including PVA.

Vertebroplasty / PVP — definition

Procedure descriptionVertebroplasty / PVP: image-guided percutaneous injection of cement (e.g., polymethyl methacrylate - PMMA) into a pathologic vertebral body.

Cement type examplePMMA is commonly used as the bone cement in vertebroplasty procedures.

Policy Revision History

2026-06-01interim updateLatest

Updated language regarding sacroplasty procedures, clarifying coding for sacral cement injection with and without cavity-creation devices (references to CPT 22511 and 0200T/0201T).

2026-04interim update

Updated policy language to distinguish between osteoporotic versus traumatic vertebral compression fractures.

2026-02interim update

Policy Summary

PayerProvidence Health Plan

PolicyPercutaneous Vertebroplasty and Sacroplasty

Policy CodePolicy 342

Change TypeMaterial coverage revisions and coding clarifications

Effective DateJun 1, 2026

Last ReviewNov 11, 2025

Next Review DateSep 1, 2026

SourceLink

On This Page

Prior authorization is recommended for unlisted codes for potentially covered services to avoid post-service denial.

Consult Noridian and WPS LCAs (see Billing and Coding LCAs) and the plan’s prior authorization requirements for other PA rules.

Step Therapy

Consider and document conservative (non‑surgical) therapy before PVA

Document that non-surgical management options were considered or trialed when clinically appropriate prior to PVA; conservative therapy includes anti‑osteoporosis therapy, analgesics, limited activity/bed rest, back brace, and physical therapy.

Record trials or consideration of non-surgical management (anti‑osteoporosis therapy, analgesics, limited activity/bed rest).
Document use of supportive measures such as back brace and physical therapy where applicable.

Note

Provider action (reserved)

Reserved for provider-action highlight. If used, ensure content reflects only explicit requirements from the policy or associated LCAs and does not introduce new obligations.

Documentation Required

Support requests with documentation for medical necessity determinations

Medical necessity determinations will be based on Company coverage and benefit criteria, the member’s unique medical history, physician recommendations and clinical notes, and may involve review by a plan medical director; providers must supply sufficient clinical documentation to support the request.

Submit member history, relevant imaging and clinical notes, and physician recommendations to substantiate medical necessity.
Be aware that determinations follow coverage criteria, benefit terms in the EOC, and may require plan medical director involvement.

Billing Rule

Follow LCAs (Noridian A56572, WPS A57630) for billing and coding documentation

Follow the plan’s referenced LCAs (Noridian A56572 and WPS A57630) and Company guidance for billing, coding and documentation requirements; all unlisted codes and coding scenarios are reviewed at claim level for medical necessity, correct coding and pricing.

Use Noridian LCA (A56572) and WPS LCA (A57630) for billing/coding guidance, coverage scenarios, and frequency/utilization limits.
All unlisted codes are reviewed at claim level; inclusion in this policy does not guarantee reimbursement and codes remain subject to provider contracts and EOC terms.

Denial Risk

Sacroplasty is not medically necessary — denial risk

Percutaneous sacral augmentation (sacroplasty) is considered not medically necessary for Medicare under this Company policy; services excluded by Medicare or the member EOC may be denied if performed.

Do not expect coverage for sacroplasty for Medicare members under this policy; submiters should verify member EOC and seek pre-service review if uncertain.
Services excluded by Medicare or the member EOC may be denied.

Denial Risk

Unlisted codes submitted for non‑covered services will be denied

Unlisted procedure codes submitted for services that are non‑covered by this policy will be denied as not covered; unlisted codes for potentially covered services should have prior authorization to reduce risk of post‑service denial.

Unlisted codes for non‑covered services addressed in this policy will be denied as not covered.
Obtain prior authorization for unlisted codes when the service may be potentially covered to avoid post‑service denial.

PurposeAimed at stabilizing the fracture and reducing pain by reinforcing the vertebral body with injected cement.

Kyphoplasty / PKP — definition

Procedure descriptionKyphoplasty / PKP: percutaneous procedure that includes insertion and inflation of a balloon prior to cement delivery to create a cavity and potentially restore vertebral height and alignment.

Relation to vertebroplastyDiffers from vertebroplasty by the added balloon step which may aid in fracture reduction and height restoration.

GoalIntended to reduce deformity and improve spinal alignment in addition to providing vertebral stabilization and pain relief.

PVA — Percutaneous vertebral augmentation

Term scopePVA (percutaneous vertebral augmentation): umbrella term encompassing both percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP).

IncludesVertebroplasty (cement injection) and kyphoplasty (balloon-assisted cavity creation plus cement delivery).

Clinical intentProcedures aim to stabilize compression fractures, reduce pain, and, with kyphoplasty, potentially restore vertebral height.

Sacroplasty — definition and coding note

DefinitionSacroplasty: term used to describe sacral vertebroplasty or sacral vertebral augmentation (injection of cement into the sacrum).

Coding distinctionWhen cement is injected into the sacrum without a balloon/mechanical device use CPT 22511; when a balloon or mechanical device is used to create a cavity, use CPTs 0200T/0201T.

Coverage noteInclusion of CPT 22511 in LCDs pertains to lumbar levels; sacral use requires recognition of the coding distinction described above.

Sacroplasty coding nuance — CPT guidance

Procedure coding nuanceSacroplasty without use of a balloon or mechanical device: report CPT 22511 (lumbosacral vertebroplasty code used for sacral cement injection without cavity-creating device).

With deviceSacroplasty with balloon or mechanical device to create a cavity: report CPTs 0200T (unilateral) or 0201T (bilateral) as appropriate.

Guidance sourcePolicy clarifies these code assignments to distinguish sacral procedures from lumbar vertebroplasty coding and LCD scope.

Percutaneous Vertebroplasty/Kyphoplasty — procedure and coding definitions

Percutaneous vertebroplastyPercutaneous injection of bone cement (e.g., PMMA) into a vertebral body to stabilize fracture; CPTs include 22510–22512 for vertebroplasty procedures.

Percutaneous kyphoplastyAugmentation involving cavity creation using a mechanical device (eg, balloon) prior to cement delivery; CPTs include 22513–22515 for kyphoplasty/augmentation with mechanical device.

ScopeIncludes procedures performed with or without cavity-creating devices; code selection depends on whether a mechanical device is used and level treated.

Revised criteria source for traumatic vertebral compression fractures (reinforcing adoption of LCD criteria for trauma-related indications).

2025-11-11annual review

Replaced L34106 with L34228 and updated companion LCA due to Noridian consolidation; no clinical criteria changes noted in this annual review.

2024-12interim update

Updated configuration to align with LCA annual review and expanded criteria beyond the scope of the LCD to provide additional medically necessary indications.

2023-09annual review

Language revised following prior Company change from 'investigational' to 'not medically necessary'.

2023-01code update

Q1 2023 code updates and conversion to new format (2/2023).