Modifiedsierra health and lifePolicy 2026T0581Q

Percutaneous Vertebroplasty and Kyphoplasty

Medical policy governing coverage and medical necessity criteria for percutaneous vertebroplasty and kyphoplasty for UnitedHealthcare Commercial and Individual Exchange benefit plans; specifies indications, imaging requirements, and exclusions for treating painful vertebral compression fractures and selected neoplastic lesions.

Policy Summary

Payersierra health and life

PolicyPercutaneous Vertebroplasty and Kyphoplasty

Policy CodePolicy 2026T0581Q

Change TypeRevised documentation and imaging examples

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain and include documented failure of optimal medical therapy and imaging correlation (CT/MRI) ruling out alternate spinal pain generators when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

Revised list of examples of causes of spinal pain to be ruled out by computed tomography (CT) or magnetic resonance imaging (MRI); removed facet arthropathy and other spinal degenerative disease.

Updated Medical Records Documentation Used for Reviews to add 'condition requiring procedure' and to replace multiple documentation phrasing items to more specific language (onset including dates; signs and symptoms and functional impairment; comorbidities; presence or absence of spinal cord compression; treatments tried, failed, or contraindicated with dates/duration/reason; results of all recent relevant imaging including assessment of bone density).

Updated definitions for 'Functional or Physical Impairment' and 'Optimal Medical Therapy'.

Updated Clinical Evidence and References sections to reflect the most current information.

22510-22515CPT procedure codes listed

6specific covered indications

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4 monthsmaximum time from pain onset

37.9% / 13.6%cement leakage rates (PVP/PKP)

34 RCTsnetwork meta-analysis size

1policy history entries

Coverage and Medical Necessity Criteria

Guideline recommendations

Guideline recommendations from major professional societies and health technology bodies relevant to vertebral augmentation (vertebroplasty and kyphoplasty):

ALL of the following

American Academy of Orthopaedic Surgeons (AAOS): Recommends against vertebroplasty for patients with osteoporotic spinal compression fracture who are neurologically intact; considers kyphoplasty an option for neurologically intact patients with symptomatic OVCF based on limited evidence showing short-term benefits in pain and function (AAOS 2011, updated 2023).
Recommendation reflects high- to moderate-quality evidence versus sham for vertebroplasty and limited evidence for kyphoplasty.
American College of Radiology (ACR): Conservative management is first-line for painful VCFs; defines failure of conservative therapy as pain refractory to oral medications or requiring parenteral narcotics/hospital admission; notes ideal preprocedural imaging not established and lists variants where percutaneous vertebral augmentation is usually appropriate (e.g., symptomatic OVCF with bone marrow edema or intravertebral cleft, new symptomatic VCF after prior vertebroplasty/surgery, benign VCF with worsening pain or deformity, pathological VCF with ongoing mechanical pain) and inappropriate for asymptomatic OVCF (ACR 2022).
Operationalizes failure of conservative therapy and patient-selection imaging considerations.
National Institute for Health and Care Excellence (NICE): Recommends percutaneous vertebroplasty and percutaneous balloon kyphoplasty without stenting as options for treating OVCFs only in people who have severe ongoing pain after a recent, unhealed vertebral fracture despite optimal pain management and whose pain has been confirmed to be at the level of the fracture by physical examination and imaging (NICE 2013, reviewed 2016).
Emphasizes confirmed pain localization and failure of optimal pain management.
SIR/AANS/CNS/ACR/ASNR/ASSR/CIRA/SNIS consensus (2014, reaffirmed 2017): States vertebral augmentation (PVP or PKP) is safe, efficacious, and durable in appropriate patients with symptomatic osteoporotic and neoplastic fractures when nonoperative therapy has not provided adequate pain relief or when pain significantly alters quality of life; advises these procedures are offered only after failure of nonoperative therapy and that there is no indication for prophylactic augmentation to prevent future fractures.
Consensus supports use in symptomatic, refractory cases and discourages prophylactic use.

Procedure and Device Coding

Applicable CPT CodesCPT

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 in addition to code for primary procedure).
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), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure).

No explicit code groups in this document segmentmixed

No codes listed

Relevant procedure and diagnosis codes (not specified in this excerpt)mixed

No codes listed

FDA device product codes (informational)mixed

NDN, LOD

FDA product codes referenced for bone cement PMMA (informational)

FDA device product codes for bone tamps (informational)mixed

HRX, HXG

FDA product codes referenced for bone tamps (informational)

Risk factors thresholds — Low HU and low BMI

Low Hounsfield unit (HU)Identified as an independent risk factor for new vertebral compression fractures after PVP or PKP (Cheng et al. retrospective cohort; OR 0.963, 95% CI 0.943–0.984; p=0.001).

Low BMIAssociated with poorer outcomes and higher risk of subsequent OVCF and worse independent living after BKP (Otsuka et al. retrospective study; low BMI was an independent predictor).

Combined riskPatients with both low HU and low BMI demonstrated increased incidence of new or subsequent VCFs in observational analyses (retrospective cohort findings).

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for percutaneous vertebral augmentation procedures. Submit documentation that correlates patient symptoms with imaging, indicates acute or subacute pain duration when applicable, and shows failure of Optimal Medical Therapy or reason conservative care is contraindicated. Documentation should include dates, duration, and rationale for discontinuation of prior treatments.

Applicable plans: Sierra Health and Life (follow member-specific benefit document and state/federal mandates).
Ensure prior auth includes: symptom correlation with imaging, pain onset/duration, prior conservative therapies tried (dates/duration/reason stopped), and functional impact.
Verify member benefits and any applicable state or federal mandate prior to authorization.

Note

Procedure Selection Justification

Selection between percutaneous vertebroplasty (PVP) and percutaneous balloon kyphoplasty (PKP) should be justified in the medical record. The record must document the clinical indication, relevant imaging findings (eg, vertebral height loss, intravertebral cleft, bone marrow edema), and the rationale for choosing one technique over another (including anticipated benefits such as deformity correction or reduced cement leakage).

Clinical Background and Rationale

This policy has a material revision with an effective date of 03/01/2026. The updated policy clarifies coverage rationale, revises examples of alternate causes of spinal pain to be excluded on imaging, and expands the required medical record documentation elements (including adding 'condition requiring procedure' and specifying dates and durations for treatments tried or contraindicated).

Definitions

Functional or Physical Impairment — definition

DefinitionA deviation from normal tissue or organ function resulting in significantly limited capacity to move, coordinate actions, or perform physical activities; evident as difficulty with physical/motor tasks, independent movement, or basic life functions.

Clinical relevanceUsed as a threshold for medical necessity when pain and functional impairment interfere with activities of daily living and justify consideration of vertebral augmentation.

DocumentationMedical records should document signs and symptoms and functional impairment that interferes with activities of daily living (onset, dates, duration).

Optimal Medical Therapy — definition

DefinitionTreatments used as first-line before moving to more invasive, risky, or complex procedures.

Examples

Policy Revision History

2026-03-01policy_revisionLatest

Revised examples of causes of spinal pain to be ruled out by CT or MRI (removed 'facet arthropathy' and 'other spinal degenerative disease'); updated medical records documentation to add 'condition requiring procedure' and make documentation elements more specific (onset including dates and duration; signs and symptoms including pain, location, severity, and functional impairment; comorbidities; presence or absence of spinal cord compression; treatments tried, failed, or contraindicated with dates/duration/reason; results of recent relevant imaging including bone density).

2026-03-01definitions_update

Updated definitions for 'Functional or Physical Impairment' and 'Optimal Medical Therapy'.

Percutaneous vertebroplasty involves percutaneous injection of bone cement (polymethylmethacrylate) into a fractured vertebral body with the primary aims of providing pain relief and improving spinal stability. Kyphoplasty uses an inflatable bone tamp to attempt vertebral height restoration prior to cement injection and may reduce cement leakage compared with vertebroplasty in some reports.

Policy Summary

Payersierra health and life

PolicyPercutaneous Vertebroplasty and Kyphoplasty

Policy CodePolicy 2026T0581Q

Change TypeRevised documentation and imaging examples

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain and include documented failure of optimal medical therapy and imaging correlation (CT/MRI) ruling out alternate spinal pain generators when requesting authorization.

SourceLink

On This Page

Document imaging findings that support the chosen procedure (CT/MRI report and measurements where available).
If PKP is chosen to reduce cement leakage risk or to achieve vertebral height restoration, include that rationale and supporting imaging.

Note

Verify Member Benefits and Mandates

Verify the member-specific benefit plan and any federal or state mandates before applying this policy. Coverage determinations are governed by the member's benefit document and applicable laws; in case of conflict, the member-specific plan controls.

Check for plan exclusions, prior authorization requirements, and any state-mandated coverage that may override standard policy language.
Confirm applicability for Sierra Health and Life plan and whether Medicare Advantage rules or other mandates apply.

Documentation Required

Imaging Requirements and Exclusion Triggers

Obtain CT or MRI to rule out alternate causes of spinal pain prior to authorization. Imaging must exclude other pain generators and document absence or presence of exclusionary findings.

Imaging must rule out: foraminal stenosis, herniated intervertebral disk, or other significant coexistent spinal or bony pain generators.
Exclusion triggers requiring denial or additional review include: clinical evidence of spinal cord compression on CT/MRI, significant vertebral destruction/collapse (eg, vertebra reduced to less than one-third of original height), or a healed VCF.

Denial Risk

Cement Leakage Considerations

Be aware of cement leakage risk and document counseling and intraoperative precautions. Cement leakage rates differ by technique and diagnosis and may be a focus of safety review.

Reported cement leakage: higher with PVP than PKP in several series; document steps taken to minimize leakage.
For malignant disease and osteonecrosis, include intraoperative findings and postoperative monitoring for leakage-related complications.

Denial Risk

Multiple Myeloma — Leakage Risk

Multiple myeloma patients have shown high rates of cement leakage in some series; documentation should reflect disease-specific risks and justification for augmentation.

Example: retrospective series reported cement leakage in 41% of treated vertebral levels in multiple myeloma—document expected benefits versus risks.
Provide disease extent on MRI/CT, vertebral integrity, and palliative intent when requesting authorization.

Denial Risk

Documentation-Related Denials

Missing required documentation items may result in denial. Ensure the medical record includes all elements needed for review to avoid processing delays or denials.

Required items: condition requiring procedure; onset with dates and duration; signs and symptoms (including pain, location, severity) and functional impairment; comorbidities; results of recent relevant imaging including assessment of bone density; treatments tried, failed, or contraindicated (with dates/duration/reasons).
Document presence or absence of spinal cord compression and any exclusionary imaging findings.

Documentation Required

Medical Records Requirement

Maintain comprehensive medical records for prior authorization and post-procedure review. Records may be requested to confirm that the member meets clinical criteria for coverage.

Include pre- and post-procedure pain scores, functional measures, imaging findings (vertebral height, kyphosis/Cobb angle, bone marrow edema, intravertebral cleft), and operative reports.
Provide documentation of counseling regarding risks (including cement leakage) and expected outcomes.

Step Therapy

Nonoperative Therapy Failure / Conservative Care First

Nonoperative therapy is first-line; augmentation is considered when conservative therapy fails or when medically necessary to address severe, refractory pain. Document failure of conservative measures or contraindications to them.

Conservative therapy examples: oral NSAIDs, opioids when appropriate, physical therapy, bracing, activity modification, and nerve block where clinically indicated.
Failure definition (per ACR): pain refractory to oral medications or requirement for parenteral narcotics and hospitalization; include dates and duration of conservative treatments.

Note

Context with Nonsurgical / Adjunctive Therapy

Context: Nonsurgical and adjunctive therapies (eg, nerve block) may be reasonable prior to vertebral augmentation in some cases; document attempts and outcomes. Consider nerve block or other less-invasive interventions when appropriate and record rationale if proceeding directly to augmentation.

Network meta-analyses and society guidance support considering nerve block as an alternative or before augmentation for some acute/subacute OVCFs.
If augmentation is performed without prior nerve block or other adjunctive measures, document clinical rationale (eg, severity of pain, neurologic status, inability to tolerate conservative care).

Oral analgesics (NSAIDs, oral opioids), physical therapy, activity modification, bracing, and other nonoperative care as appropriate prior to vertebral augmentation.

Policy roleProcedure indicated only after failure to respond to Optimal Medical Therapy; documentation of therapies tried and dates/duration is required.

Osteonecrosis — definition (includes Kümmell disease)

DefinitionA disease caused by reduced blood flow to bone leading to bone breakdown; includes Kummell (Kümmell) disease and may be associated with steroids, alcohol, injury, radiation, chemotherapy, or organ transplant-related risks.

Clinical consequenceMay lead to delayed vertebral collapse and instability; can produce painful, unstable fractures that may be considered for augmentation depending on neurologic status.

TerminologyAlso referred to as avascular necrosis, aseptic necrosis, pseudarthrosis, or Kummell disease in the source text.

Vertebral Hemangiomas (aggressive) — definition

DefinitionBenign vascular tumors of the vertebral body; a rare aggressive subset exhibits extraosseous extension, bone expansion, disturbed blood flow, and can cause compression fractures (most often T3–T9).

Clinical noteWhen symptomatic with aggressive features, vertebral hemangiomas have shown high pain-relief rates after PVP in case series and may be considered for augmentation.

Imaging/levelAggressive hemangiomas are most frequently located between T3 and T9; correlate imaging with symptoms prior to intervention.

Vertebroplasty (PVP) — definition/description

Procedure descriptionPercutaneous injection of polymethylmethacrylate (bone cement) into a fractured vertebral body to stabilize the spine and reduce pain; described in CPT codes 22510–22512 for vertebroplasty.

Clinical evidenceEvidence comparing PVP with sham or conservative care is mixed; some high-quality reviews do not support routine vertebroplasty for acute/subacute OVCFs (Cochrane review).

RisksCement leakage is common and may cause complications; consider risk-benefit and document indications carefully.

Balloon kyphoplasty (BKP/PKP) — definition/description

Procedure descriptionInflation of an intravertebral balloon (cavity creation) to restore vertebral height followed by injection of bone cement; represented by CPT codes 22513–22515 for kyphoplasty.

Radiographic vs clinical outcomesCompared with vertebroplasty, kyphoplasty tends to better restore vertebral height and reduce cement leakage but often yields similar pain and disability outcomes in many studies.

Resource useKyphoplasty may require greater cement volume, operative time, fluoroscopy, and cost compared with vertebroplasty; select technique based on radiographic goals and patient risk profile.

Vertebral augmentation — umbrella definition for PVP and PKP

Umbrella definitionVertebral augmentation refers to percutaneous vertebroplasty (PVP) or balloon kyphoplasty (PKP) involving injection of bone cement (PMMA) into a vertebral body for pain relief and structural support in VCFs due to osteoporosis or malignancy.

IndicationsUsed for symptomatic osteoporotic VCFs with marrow edema/intravertebral cleft, malignant VCFs for palliative benefit, and select unstable fractures (eg, osteonecrosis) after conservative therapy fails.

ConsiderationsAssess imaging to exclude other pain generators, document failure of conservative therapy, and weigh risks (new/adjacent fractures, cement leakage).

Kümmell disease — definition and clinical considerations

DefinitionA form of osteonecrosis presenting as delayed vertebral collapse with an intravertebral vacuum cleft and potential instability; often staged and may be described as Kümmell disease.

Clinical considerationsFor neurologically intact, osteoporotic Kümmell disease, both PVP and PKP relieve pain; PKP often yields better radiographic correction and lower cement leakage but greater resource use—select procedure based on instability, neurologic status, and imaging.

DocumentationDocument imaging (vacuum cleft, stage), neurologic exam, and prior conservative therapy when considering augmentation for Kümmell disease.

Failure of conservative therapy — definition

DefinitionFailure of conservative therapy is defined as pain refractory to oral medications (NSAIDs and/or narcotics), contraindication to such medications, or requirement for parenteral narcotics and hospital admission.

Clinical implicationVertebral augmentation is usually offered only after conservative management has not provided adequate pain relief or when pain significantly alters quality of life.

Documentation requirementsMedical records should include treatments tried, failed, or contraindicated with dates, duration, and reason for discontinuation to support prior therapy failure.

Symptomatic OVCF with marrow edema or intravertebral cleft — definition indicating potential coverage

DefinitionA symptomatic osteoporotic vertebral compression fracture (OVCF) with imaging evidence of bone marrow edema or an intravertebral cleft, indicating the fracture is the source of pain and may be appropriate for vertebral augmentation.

Clinical requirementPain must be confirmed at the fracture level by physical exam and correlated with imaging (MRI or CT demonstrating marrow edema or intravertebral cleft).

Coverage noteThis imaging finding is listed as a usual appropriateness criterion supporting augmentation when paired with refractory pain and functional impairment.

Functional or Physical Impairment — updated definition in this revision

Updated definitionFunctional or Physical Impairment: deviation from normal tissue or organ function causing significantly limited capacity to move, coordinate actions, or perform physical activities, evident as difficulty in physical/motor tasks, independent movement, or basic life functions.

Policy update impactOperational reviewers should request updated, more specific documentation elements (eg, onset including dates; signs/symptoms and functional impairment) during medical record review.

Documentation linkEnsure medical records explicitly state functional impairment interfering with activities of daily living when justifying augmentation.

Optimal Medical Therapy — updated definition in this revision

Updated definitionOptimal Medical Therapy: treatments used as first-line before moving to more invasive, risky, or complex procedures.

Policy expectationProcedure is indicated only after failure to respond to Optimal Medical Therapy; reviewers should see documentation of treatments tried, dates, duration, and reasons for discontinuation.

Examples and documentationIncludes oral analgesics, physical therapy, bracing, and other nonoperative measures as appropriate; include dates and duration in medical record documentation.