Percutaneous Vertebroplasty and Kyphoplasty (for Pennsylvania Only)

Coverage Summary

This Pennsylvania-specific policy (Policy CS330PAD, effective March 1, 2025) defines UnitedHealthcare’s coverage stance for percutaneous vertebroplasty (PVP) and kyphoplasty (KP). The policy considers these procedures medically necessary for selected patients with symptomatic osteoporotic or neoplastic vertebral compression fractures that are within 4 months of pain onset and have failed Optimal Medical Therapy, when imaging (CT or MRI) excludes other spinal pain generators and certain anatomic contraindications. For indications outside the listed covered diagnoses the policy reflects a mixed stance—evidence supports use in specific refractory osteoporotic and malignant fractures but is limited or conflicting for other indications.

Key thresholds and quick facts

Symptom durationOnset of pain within 4 months required (<= 4 months)

Vertebral height exclusionSignificant collapse excluded: vertebra reduced to less than one-third of original height (must be absent on CT/MRI)

Listed Covered Indications6 indications: steroid-induced fracture; osteoporotic VCF; osteolytic metastatic disease; aggressive vertebral hemangioma; multiple myeloma; unstable fractures due to osteonecrosis (e.g., Kummell disease)

Listed CPT Codes6 CPT codes listed (22510, 22511, 22512, 22513, 22514, 22515)

Evidence summary (one line)Multiple systematic reviews and meta-analyses cited (Cochrane Buchbinder 2018; Zhao et al. 2017 network meta-analysis; Mattie et al. 2016; Hayes HTA updates and many others) showing mixed evidence—improvements in pain/function in selected patients but RCT/sham trials conflict

Medically Necessary (Covered) Criteria

Not Medically Necessary (Unproven) Criteria

Evidence Summaries by Indication

Percutaneous vertebroplasty (PVP) and percutaneous balloon kyphoplasty (KP) are image-guided interventional procedures that inject an acrylic polymer (e.g., PMMA) into a vertebral body to stabilize fractures and relieve pain; KP additionally uses an inflatable balloon (bone tamp) to attempt restoration of vertebral height before cement injection. The policy summarizes that the overall evidence base supports vertebral augmentation as a safe and effective option in appropriately selected patients with symptomatic osteoporotic or neoplastic fractures refractory to conservative care, while randomized sham-controlled trials and systematic reviews report limited or conflicting benefit for some osteoporotic fracture presentations, creating heterogeneity in interpretation across indications.

Major guideline and evidence reviews show conflicting recommendations: the AAOS (2010, updated 2023) recommends against vertebroplasty for neurologically intact osteoporotic compression fractures and views kyphoplasty as an option with limited short-term benefit; AACE/ACE guidance (2016/2020) does not endorse vertebroplasty or kyphoplasty as first-line treatments; the ACR (2022) and ACR-supported practice parameters/consensus statements consider conservative care first-line and describe vertebral augmentation as usually appropriate in select symptomatic VCFs (e.g., marrow edema/intravertebral cleft, pathological VCF with mechanical pain); NICE TA279 (2013, confirmed 2016) endorses PVP and BKP as options only for patients with severe ongoing pain from a recent unhealed fracture despite optimal pain management; and technology assessments (Hayes, Cochrane) and systematic reviews report mixed results—Hayes finds moderate-quality evidence that KP may benefit some patients not responding to conservative therapy, while the Cochrane review (Buchbinder et al., 2018) found high- to moderate-quality evidence that vertebroplasty does not demonstrate clinically important benefit versus sham for routine use. These conflicting positions underpin the policy’s selective, indication- and evidence-based coverage criteria.

Coding

Applicable CPT procedure codes (reference list)CPT

22510	Percutaneous vertebroplasty; vertebral body, cervicothoracic (bone biopsy included when performed), unilateral or bilateral injection, inclusive of all imaging guidance
22511	Percutaneous vertebroplasty; vertebral body, lumbosacral (bone biopsy included when performed), unilateral or bilateral injection, inclusive of all imaging guidance
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 (e.g., kyphoplasty), 1 vertebral body, thoracic, inclusive of all imaging guidance
22514	Percutaneous vertebral augmentation including cavity creation using mechanical device (e.g., kyphoplasty), 1 vertebral body, lumbar, inclusive of all imaging guidance
22515	Percutaneous vertebral augmentation including cavity creation using mechanical device (e.g., kyphoplasty), each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

No procedural or billing codes present in this partmixed

No codes listed

Regulatory device product codes referencedmixed

No codes listed

Provider Actions / Prior Authorization

Documentation Required

Imaging confirmation required

CT or MRI confirmation is required to establish diagnosis, exclude other spinal pain generators (foraminal stenosis, facet arthropathy, herniated disk, other degenerative disease, or other spinal/bony pain sources), and to document absence of significant vertebral collapse, spinal cord compression, or healed VCF prior to vertebroplasty or kyphoplasty.

Documentation Required

Conservative therapy trial documented

Documentation must show failure to respond to Optimal Medical Therapy (first-line treatments such as analgesics, bed rest, and external bracing) before performing vertebroplasty or kyphoplasty.

Definitions

Term	Definition
Functional or Physical Impairment	Deviation from normal tissue or organ function leading to significant limitations in movement, coordination, physical activities, or basic life functions.
Optimal Medical Therapy	First-line treatments (e.g., analgesics, bed rest, external bracing) used before moving to more invasive procedures.
Osteonecrosis	Disease caused by reduced blood to bone leading to collapse; includes Kummel disease; causes include steroids, alcohol, injury.
Vertebral Hemangiomas (aggressive)	Benign vascular tumors of the spine with extra-osseous extension, bone expansion, disturbed blood flow, and occasional compression fractures; often T3-T9.
PVP	Percutaneous vertebroplasty.
PKP	Percutaneous kyphoplasty.
KP/BKP	Kyphoplasty / balloon kyphoplasty.
BFMC / BFC	Bone-filling mesh container / bone-filling container (adjunct to vertebral augmentation).
VCF	Vertebral compression fracture.
KD	Kummell's disease (osteonecrosis-related unstable vertebral fracture).

Key Evidence & Guidelines

Source	Key takeaway
Hayes Health Technology Assessment (updated 2021)	Moderate-quality evidence that kyphoplasty may be beneficial for some patients with VCF not responding to conservative treatment; KP and VP provide similar improvements.
Cochrane review (Buchbinder et al., 2018)	High- to moderate-quality evidence does not support vertebroplasty for routine treatment of acute/subacute osteoporotic VCFs versus sham.
Zhao et al. (2017) network meta-analysis	VP best for pain relief; KP best for function/quality of life and lowest risk of new fractures; limited by indirectness
Mattie et al. (2016) meta-analysis	PVP effect exceeded conservative therapy up to 1 year for pain relief; significant effect sizes at multiple timepoints
Sorensen et al. (2019) systematic review	Clinically relevant improvements in pain, ODI, and KPS for malignant VCFs treated with PVP or KP; cement leakage common but rarely symptomatic
Zhang et al. (2022) (Kummell's disease)	PKP associated with better Cobb angle correction, vertebral height improvement and lower cement leakage than PVP but with greater resource use; no differences in long-term VAS/ODI.
Dai et al. 2021	Prospective study (64 pts) found no significant VAS/ODI differences between PVP and PKP; PKP had longer surgical time, higher cost and fluoroscopy times; PKP showed better imaging correction.
AAOS guideline (2010, updated 2023)	Recommends against vertebroplasty for neurologically intact osteoporotic compression fractures; considers kyphoplasty an option with limited evidence of short-term benefit.
AACE/ACE guideline (2016, updated 2020)	Do not recommend vertebroplasty or kyphoplasty as first-line treatment for vertebral fractures.
ACR appropriateness criteria (revised 2022)	Conservative management is first-line; vertebral augmentation usually appropriate for symptomatic VCF with marrow edema/intravertebral cleft, prior vertebroplasty/surgery, benign VCF with worsening pain/deformity, pathological VCF with ongoing mechanical pain; not appropriate for asymptomatic osteoporotic VCF.
NICE TA279 (2013, confirmed 2016) / SIR statement (2014, reaffirmed 2017)	Recommend PVP and balloon kyphoplasty as options only for people with severe ongoing pain after a recent unhealed vertebral fracture despite optimal pain management and with pain confirmed at the level of the fracture; consensus that augmentation is safe and efficacious in appropriate symptomatic osteoporotic and neoplastic fractures after non-operative therapy fails.

Revision History

March 1, 2025revisedLatest

Archived previous policy version CS330PAC. Supporting Information Updated Clinical Evidence and References sections to reflect the most current information.