UnitedHealthcare Vertebroplasty Kyphoplasty Coverage

Medical Necessity Criteria

Medically necessary — general

Percutaneous vertebroplasty and kyphoplasty are medically necessary when ALL of the following are met:

ALL of the following

Procedure is being used to treat pain causing Functional or Physical Impairment in cervical, thoracic, or lumbar vertebral bodies
Pain onset is within 4 months<= 4 months from onset
Pain has failed to respond to Optimal Medical Therapy
Failure of conservative therapy defined as pain refractory to oral medications (NSAIDs and/or narcotics) or contraindication to such medications or requirement for parenteral narcotics and hospital admission
ONE of the following diagnoses
- Osteoporotic vertebral compression fracture (VCF)
- Steroid-induced vertebral fracture
- Osteolytic metastatic disease involving a vertebral body
- Multiple myeloma involving a vertebral body
- Vertebral hemangioma with aggressive features
- Unstable fractures due to osteonecrosis (e.g., Kümmell's disease)
CT or MRI has ruled out other causes of spinal pain (foraminal stenosis, facet arthropathy, herniated intervertebral disk, other spinal degenerative disease, other significant coexistent spinal or bony pain generators)
AND the following ABSENT findings (none 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 MRIvertebra reduced to less than one-third of its original height (exclusion)
- Healed vertebral compression fracture as confirmed by CT or MRI
- Lesions of the sacrum or coccyx (these are excluded; refer to Minimally Invasive Spine Surgery Procedures (for Idaho Only) for sacral augmentation)
- Asymptomatic vertebral compression fractures (VCFs)

Imaging (CT or MRI) and clinical documentation meet the above requirements and absence of excluded findings is confirmed

Not medically necessary / Unproven

Percutaneous vertebroplasty and kyphoplasty are considered not medically necessary when the indication is other than those listed above due to insufficient evidence of efficacy.

ANY of the following

Indications other than the specified osteoporotic, steroid-induced, osteolytic metastatic, multiple myeloma, aggressive vertebral hemangioma, or osteonecrosis-related unstable fractures

Evidence synthesis findings — comparative efficacy and safety

Summarized conclusions from systematic reviews, meta-analyses, RCTs and retrospective studies:

ALL of the following

For osteoporotic VCFs, PVP/VP provides greater early pain relief than conservative treatment; effect may persist up to 1 year in some analyses (e.g., Mattie et al. 2016; Xie et al. 2017).
Comparisons between VP and KP often show no difference for some long-term outcomes; VP may be best for pain relief, KP may improve function/quality of life and reduce new fractures in network meta-analysis (Zhao et al. 2017).
Blinded randomized trials suggest no benefit of PVP over local anesthetic sham, creating uncertainty; additional sham-controlled RCTs of BKP are recommended.
For malignant/metastatic VCFs and multiple myeloma, PVP and KP generally provide clinically relevant reductions in pain and improvements in function and quality of life with low rates of major complications (systematic reviews and retrospective series).

Safety signals / complications described

Reported complications and comparative observations:

ANY of the following

Cement leakage — frequently reported and commonly asymptomatic; symptomatic events rare. Reported rates: PVP ~37.9%, KP ~13.6% in one review.
Pulmonary embolism — rare case reports (e.g., single pulmonary embolism reported in a case series).
Symptomatic serious complications requiring open surgery are very uncommon (<0.01% in one large cohort).

Indications summarized from evidence and guideline consensus

Procedures are considered in appropriate patients when nonoperative therapy fails or in selected neoplastic cases; guideline variation is noted across societies:

ANY of the following

Symptomatic osteoporotic vertebral compression fracture(s) refractory to conservative medical therapy (e.g., pain not controlled with oral medications, or requiring parenteral narcotics/hospital admission).
Reflects ACR and multiple society statements defining failure of conservative therapy.
New symptomatic vertebral compression fracture with bone marrow edema or intravertebral cleft on imaging.
Listed by ACR as usually appropriate.
Benign vertebral compression fracture with worsening pain, deformity, or pulmonary dysfunction.
Listed by ACR as usually appropriate.
Pathological vertebral compression fracture with ongoing or increasing mechanical pain (e.g., neoplastic disease) when refractory to conservative therapy or when palliation is the goal.

Procedure Codes

Applicable CPT codes (vertebroplasty / vertebral augmentation)CPT

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)

Not provided in this document (no procedural or diagnosis codes listed in Part 3)mixed

No codes listed

Documentation, Prior Authorization, and Denial Risk

Documentation Required

Imaging required to document causes and exclusions

CT or MRI must be performed and must rule out other causes of spinal pain and document absence of spinal cord compression, significant vertebral collapse, or healed VCF. Checklist: - Cross‑sectional imaging (CT or MRI) excluding foraminal stenosis, facet arthropathy, herniated intervertebral disk, other spinal degenerative disease, or other coexistent spinal/bony pain generators; - Imaging documentation that there is no clinical evidence of spinal cord compression; - Imaging confirmation that the vertebra is not significantly collapsed or destroyed (not reduced to < one‑third of original height); - Imaging evidence excluding a healed vertebral compression fracture.

CT or MRI excluding other spinal pain generators (foraminal stenosis, facet arthropathy, herniated disk, other degenerative disease)
Imaging documentation of absence of spinal cord compression
Imaging showing no significant vertebral collapse (vertebra not reduced to <1/3 height)
Imaging ruling out healed VCF

Clinical and Policy Context

Percutaneous vertebroplasty (PVP/VP) is an image-guided, percutaneous injection of an acrylic polymer (commonly polymethylmethacrylate, PMMA) into a fractured vertebral body to provide pain relief and mechanical stabilization for osteoporotic or osteolytic lesions that have not responded to conservative care. Kyphoplasty (also called balloon kyphoplasty or BKP/PKP) is a variation in which an inflatable bone tamp (balloon) is used to create or restore vertebral height prior to cement injection; this step is intended to reduce kyphotic deformity and may decrease cement extrusion compared with PVP. (Description: PVP/VP and KP/PKP).

Both procedures are performed with fluoroscopic or CT guidance and are intended to: relieve pain, improve function and quality of life, and provide vertebral body stabilization to prevent further collapse in selected patients. Indications most commonly supported by the literature and professional society guidance include painful osteoporotic vertebral compression fractures and selected pathologic (neoplastic) fractures; kyphoplasty may offer greater radiographic height restoration and lower rates of cement leakage but at higher resource use. (Intended benefits: pain relief, function, stability; KP vs PVP comparative outcomes).

The evidence base shows clinically relevant benefit for carefully selected patients but is heterogeneous. For acute/subacute osteoporotic vertebral compression fractures, many trials and meta-analyses report greater early pain relief with vertebral augmentation versus conservative management and durable improvement in some analyses up to one year, while sham-controlled trials of vertebroplasty introduce uncertainty about efficacy for some patients. For malignant or metastatic VCFs and multiple myeloma, consistent series and systematic reviews report meaningful palliative reductions in pain and improved function with low rates of major complications. For osteonecrosis-related unstable fractures (Kümmell's disease), kyphoplasty often achieves better height restoration and less cement leakage than vertebroplasty, with similar symptom improvement across techniques. Overall, use should be limited to patients meeting specific clinical and imaging criteria and after failure of Optimal Medical Therapy. (Evidence nuance: supportive in selected patients; limited/inconclusive for other indications).

UnitedHealthcare created this Idaho‑specific policy effective 06/01/2025 to define covered indications, required imaging and exclusions, and to emphasize documentation of failure of conservative therapy and imaging correlation of pain to the treated level before vertebral augmentation is authorized. Providers should follow the policy’s listed indications, exclusions (for example, significant vertebral collapse—vertebra reduced to less than one‑third of original height, spinal cord compression, healed or asymptomatic fractures, and sacrococcygeal lesions), and prior authorization requirements where applicable. (Policy scope, exclusions, and effective date).

Defined Terms

Definitions

Functional or Physical ImpairmentDeviation from normal function of a tissue or organ resulting in significant limitation in movement, coordination, or performance of physical activities; evidenced by difficulty with physical/motor tasks, independent movement, or basic life functions.

Optimal Medical TherapyTreatments that are employed as first line before moving to more invasive, risky or complex procedures (e.g., analgesics, bed rest, external bracing).

OsteonecrosisBone disease caused by reduced blood flow to bones (also called avascular necrosis or Kummel disease); can lead to bone collapse and unstable fractures.

Vertebral Hemangiomas (aggressive)Benign vascular spinal tumors that in aggressive forms have extra-osseous extension, bone expansion, disturbed blood flow, and may cause compression fractures (most often T3–T9).

PVP/VPPercutaneous vertebroplasty — image-guided injection of bone cement into a vertebral body to provide pain relief and stabilization.

Clinical Thresholds and Key Metrics

Eligibility thresholds

Pain duration threshold<= 4 months from onset

Significant vertebral collapse exclusion thresholdVertebra reduced to less than one-third of its original height (exclusion)

Failure of conservative therapy (per ACR definition)Pain refractory to oral medications (NSAIDs and/or narcotics), or contraindication to such medications, or requirement for parenteral narcotics and hospital admission.

4 monthsMaximum duration from pain onset to eligibility for procedure

6CPT codes listed in this policy excerpt

7Indications considered medically necessary when criteria met

Policy Update Changes

2025-06-01Policy createdLatest

New Medical Policy: Percutaneous vertebroplasty and kyphoplasty (Idaho only) established effective June 1, 2025.

OpenPayer

Percutaneous Vertebroplasty and Kyphoplasty (for Idaho Only)

Medical Necessity Criteria

Procedure Codes

Documentation, Prior Authorization, and Denial Risk

Clinical and Policy Context

Defined Terms

Clinical Thresholds and Key Metrics

Policy Update Changes