CurrentUnitedHealthcarePolicy CS330PA.E

Percutaneous Vertebroplasty Kyphoplasty Pa Cs

Policy governs medical necessity coverage criteria for percutaneous vertebroplasty and kyphoplasty for members in Pennsylvania, specifying eligible indications, required imaging exclusions, timing relative to pain onset, and exclusions. Includes applicable CPT procedure codes and documentation requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty Kyphoplasty Pa Cs

Policy CodePolicy CS330PA.E

Change TypeRevisions and clarifications (definitions, documentation, examples to rule out)

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain and maintain medical records that document history, exam, imaging (CT/MRI ruling out alternative spinal pain causes), and failure of Optimal Medical Therapy to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Revised list of examples of causes of spinal pain to be ruled out by CT or MRI; removed examples including facet arthropathy and other spinal degenerative disease.

Added clarifying language about medical records documentation used for reviews, emphasizing that documentation may be required and must support medical necessity.

Updated definitions for Functional or Physical Impairment, Optimal Medical Therapy, Osteonecrosis, and Vertebral Hemangiomas.

Updated Clinical Evidence and References sections to reflect current information.

6Listed Covered Indications

PAState-specific policy (Pennsylvania)

AAOS/ACR/NASS

B/IRecommendation Grades present

1-37.9%Reported cement leakage range

Coverage Summary

This Pennsylvania-only policy covers with criteria percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) when documentation shows pain causing Functional or Physical Impairment in cervical, thoracic, or lumbar vertebral bodies, pain onset is within ≤ 4 months, and the pain has failed to respond to Optimal Medical Therapy. The policy specifies eligible indications (osteoporotic VCF, steroid-induced fracture, osteolytic metastatic disease, multiple myeloma, aggressive vertebral hemangioma, and unstable fractures from osteonecrosis such as Kümmell disease), required CT or MRI to rule out other causes of spinal pain, and listed exclusions (e.g., spinal cord compression, significant vertebral collapse to less than one-third original height, healed or asymptomatic VCFs, sacral/coccygeal lesions). Effective date: May 1, 2026. Note: This policy applies only to Pennsylvania; requests not meeting Pennsylvania-specific criteria will be evaluated case-by-case per state exceptions.

Surface thresholds and quick facts

Pain onset window≤ 4 months

Significant vertebral collapse exclusionvertebra reduced to less than one-third of its original height

Persistent long-term painVAS > 3 for > 6 months

Listed Covered Indications6

State-specific policyPennsylvania only

Major professional societies citedAAOS, ACR, NASS (among others)

Proportion with persistent pain~1/3 of adults with OVCF may have persistent pain without augmentation

Policy numberCS330PA.E

SubjectPercutaneous Vertebroplasty and Kyphoplasty (Pennsylvania Only)

Medically Necessary and Exclusion Criteria

Medically Necessary (Coverage) Criteria

Covered when ALL of the following are met:

ALL of the following

Indication is ONE of
- Osteoporotic vertebral compression fracture (VCF)
- Steroid-induced vertebral fracture
- Osteolytic metastatic disease involving a vertebral body
- Multiple myeloma involving a vertebral body

Evidence and Guideline Summary

Clinical indications summarized in literature and guidelines

Evidence/guidance indicates procedure appropriateness varies by indication and clinical scenario:

Indications supported by literature/guidelines

Pathological vertebral compression fractures due to metastatic disease or multiple myeloma: PVP and PKP provide clinically relevant improvements in pain, ODI, and KPS; cement leakage common but rarely symptomatic.
Symptomatic vertebral hemangioma refractory to medical management: PVP associated with significant pain relief and low complication rates in case series.
Kümmell disease (osteonecrosis) without neurological deficit: Both PKP and PVP are effective; PKP tends to provide better kyphosis correction and lower cement leakage but higher resource use.
Acute osteoporotic vertebral compression fractures (OVCFs): NASS Grade A recommends vertebral augmentation for adults with acute OVCFs; AAOS recommends against vertebroplasty but considers kyphoplasty an option.

Imaging, Preprocedure Evaluation, and Documentation

Imaging and Preprocedure Evaluation (coverage rationale updates)

Imaging to rule out other causes of spinal pain and to localize fracture pain:

Computed tomography (CT) or magnetic resonance imaging (MRI) should be used to rule out causes of spinal pain and to confirm that the pain corresponds to the fractured level.

Policy history revised list of examples to be ruled out by CT/MRI (05/01/2026).

Documentation / Medical Records

Medical record requirements for coverage assessment:

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage and must fully support medical necessity for the requested services. Documentation includes relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; must be legible and available upon request.

Documentation includes relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; must be legible and available upon request.

Provider Actions and Authorization Requirements

Prior Authorization

Pennsylvania-specific policy application

This policy applies only in Pennsylvania. Requests that do not meet the Pennsylvania-specific criteria will be evaluated case-by-case and may require preauthorization per Pennsylvania exceptions and code of regulations.

Documentation Required

Medical record documentation required

Obtain and maintain complete, legible medical records that fully support medical necessity. Required documentation includes relevant medical history, physical examination findings, and pertinent diagnostic test results such as CT or MRI showing fracture characteristics and ruling out exclusions. Records must be maintained in the patient's chart and made available upon request for review.

Relevant medical history and physical exam
Results of pertinent diagnostic tests or procedures (including CT or MRI)

Procedure Coding (reference only)

Definitions

Functional or Physical Impairment: deviation from normal tissue or organ function resulting in a significantly limited capacity to move, coordinate actions, or perform physical activities, exhibited by difficulties with physical/motor tasks, independent movement, or basic life functions.

Optimal Medical Therapy: first-line, noninvasive treatments used before more invasive procedures (e.g., analgesics, bed rest, external bracing).

Osteonecrosis: disease from reduced blood flow to bone leading to bone breakdown; includes Kummel disease; causes include steroid use, alcohol, injury; nonsurgical treatments may relieve pain but do not cure.

Vertebral Hemangiomas: benign vascular tumors of the bony spine usually asymptomatic; aggressive hemangiomas have extraosseous extension, bone expansion, disturbed blood flow, and possible compression fractures.

PVP (Percutaneous Vertebroplasty): cement injection into a vertebral body to relieve pain and provide stability.

PKP (Percutaneous Kyphoplasty): balloon-mediated vertebral augmentation where an inflatable bone tamp restores height prior to cement injection.

Kümmell disease: post-traumatic delayed vertebral collapse/osteonecrosis characterized by an intravertebral cleft.

Polymethylmethacrylate (PMMA) bone cement: implanted acrylic polymer material used in vertebral augmentation; multiple PMMA products are FDA-cleared as Class II devices.

Revision History

05/01/2026material - revisedLatest

Revised list of examples of causes of spinal pain to be ruled out by CT or MRI; removed examples including facet arthropathy and other spinal degenerative disease.

05/01/2026material - addedLatest

Added clarifying language about medical records documentation used for reviews, emphasizing that documentation may be required and must support medical necessity; benefit coverage determined by federal, state, or contractual requirements.

05/01/2026

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty Kyphoplasty Pa Cs

Policy CodePolicy CS330PA.E

Change TypeRevisions and clarifications (definitions, documentation, examples to rule out)

Effective DateMay 1, 2026

Next Review Date

SourceLink

On This Page

Vertebral Hemangioma with aggressive features

Unstable fractures due to Osteonecrosis (e.g., Kummel disease)

Functional or Physical Impairment causing pain in cervical, thoracic, or lumbar vertebral bodies

As defined in policy Definitions

Pain onset within<= 4 months

Procedure performed within 4 months of pain onset

Failed to respond to Optimal Medical Therapy

See Definitions for Optimal Medical Therapy

ALL of the following

Computed tomography (CT) or magnetic resonance imaging (MRI) has ruled out other causes of spinal pain, including but not limited to foraminal stenosis, herniated intervertebral disk, or other significant coexistent spinal or bony pain generators

None of the following are present

Clinical evidence of spinal cord compression as confirmed by CT or MRI
Significant vertebral collapse or destruction (e.g., vertebra reduced to less than one-third of its original height), as confirmed by CT or MRI
Healed vertebral compression fracture (VCF), as confirmed by CT or MRI
Lesions of the sacrum or coccyx
Asymptomatic VCFs
VCFs responding appropriately to conservative therapy

Not Medically Necessary / Unproven Indications

Not covered (Not Medically Necessary) when ANY of the following apply:

ANY of the following

Any indication not listed in the covered indications (i.e., any indication other than osteoporotic VCF, steroid-induced vertebral fracture, osteolytic metastatic disease of a vertebral body, multiple myeloma involving a vertebral body, vertebral hemangioma with aggressive features, or unstable fractures due to osteonecrosis)

Percutaneous vertebral augmentation usually appropriate for symptomatic OVCF with bone marrow edema or intravertebral cleft, new symptomatic VCF with prior vertebroplasty/surgery, benign VCF with worsening pain/deformity/pulmonary dysfunction, and pathological VCF with ongoing or increasing mechanical pain (per ACR).

Percutaneous vertebroplasty (PVP) injects bone cement into a fractured vertebral body to relieve pain and stabilize the spine; kyphoplasty (PKP) uses an inflatable bone tamp to restore vertebral height prior to cement injection. Both procedures are primarily used for osteoporotic vertebral compression fractures (OVCFs) and for neoplastic (osteolytic/metastatic or multiple myeloma) lesions that are refractory to medical therapy, with the goal of reducing pain, improving function and quality of life, and in some cases restoring vertebral height.

Evidence synthesis: multiple systematic reviews, randomized trials, cohort studies, and technology assessments indicate vertebral augmentation can provide clinically meaningful reductions in pain and improvements in function and quality of life for selected patients with symptomatic OVCFs and cancer-related VCFs; cement leakage is commonly reported but symptomatic complications are uncommon. Evidence is inadequate to support use for indications not listed in the covered indications.

Source	Key findings
Evidence summary	Multiple systematic reviews, RCTs, cohort studies, and technology assessments show vertebral augmentation can improve pain and function in selected patients with symptomatic OVCFs; evidence inadequate for other indications.
Sorensen et al. (2019) systematic review	In malignant VCFs pain improved (PVP: 7.48→3.00; PKP: 7.05→2.96); ODI and KPS improved; cement leakage common (PVP 37.9% vs PKP 13.6%) but symptomatic complications rare.
Qi et al. (2016) meta-analysis	PVP associated with significant pain reduction (case-control HR -2.83; single-arm HR -4.79) and KPS improvement (HR 16.31) in spinal tumors.
NASS 2024	Grade A: vertebral augmentation recommended for acute OVCFs; kyphoplasty and vertebroplasty similar for pain relief; kyphoplasty provides better height restoration (Grade B).
AAOS 2011 (updated 2023)	Recommends against vertebroplasty for osteoporotic VCF in neurologically intact patients; considers kyphoplasty an option based on limited evidence.
Policy Application (Pennsylvania only)	Policy applies to Pennsylvania; medical records documentation may be required and must fully support medical necessity for coverage reviews.
ECRI 2025 / Technology assessments	ECRI concluded kyphon balloon kyphoplasty is safe and improves pain, function, and quality of life better than conservative management at short- and intermediate-term follow-up.

Benefit coverage is determined by federal, state, or contractual requirements and applicable laws which may mandate coverage; such requirements govern in event of conflict with this policy.

Evidence of failure of Optimal Medical Therapy

Legible documentation maintained in the medical record and available upon request

Documentation Required

Appropriate indication documentation

Document the indication clearly: symptomatic status (pain refractory to conservative/Optimal Medical Therapy), specific imaging findings at the fractured level (e.g., bone marrow edema, intravertebral cleft), prior interventions, and current neurologic status to demonstrate appropriateness per guideline-based criteria.

Symptomatic pain not responding to Optimal Medical Therapy
Imaging findings correlating pain to the fracture level (bone marrow edema, intravertebral cleft)
Record of prior interventions or treatments tried
Current neurologic exam/status

Documentation Required

Preprocedure imaging and documentation

Preprocedure imaging with CT or MRI is required to rule out other causes of spinal pain and to confirm the pain corresponds to the fractured level. Maintain and make available records of imaging, history, physical exam, and diagnostic test results to support medical necessity if requested.

CT or MRI ruling out alternative spinal pain generators and confirming fracture-level pain
Maintain imaging and related records in the medical record
Make records available upon request for review

Denial Risk

Risk of noncoverage for asymptomatic fractures or first-line use

Procedures for asymptomatic vertebral compression fractures or use as a first-line treatment without documented failure of conservative/Optimal Medical Therapy are generally considered inappropriate and are at risk for denial.

Asymptomatic VCFs are listed as not present for coverage
Conservative management is first-line; failure of conservative therapy is required for augmentation
Society guidance does not recommend vertebroplasty/kyphoplasty as first-line in many cases

Documentation Required

Adhere to contractual/federal/state requirements

Verify federal, state, and contractual benefit requirements before applying this policy. Benefit coverage may be governed by applicable laws or contracts that override or mandate coverage, and medical records may be required to assess whether criteria are met.

Check applicable federal, state, and contractual benefit requirements
Recognize that such requirements govern in the event of a conflict with this policy
Ensure medical records support medical necessity and are available if requested

non-material - revised

Definitions section updated (Functional or Physical Impairment, Optimal Medical Therapy, Osteonecrosis, Vertebral Hemangiomas).

05/01/2026non-material - revisedLatest

Supporting Information updated: Clinical Evidence and References sections refreshed to reflect current information.