ModifiedUnitedHealthcarePolicy CS330ID.C

Percutaneous Vertebroplasty and Kyphoplasty (for Idaho Only)

This policy governs coverage and medical necessity criteria for percutaneous vertebroplasty and kyphoplasty for members in the state of Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty and Kyphoplasty (for Idaho Only)

Policy CodePolicy CS330ID.C

Change TypeRevisions to imaging exclusion examples and updated definitions

Effective DateJun 1, 2026

Next Review Date

Key ActionFor Idaho members, procedures identified by CPT codes 22510–22515 must meet the policy's medical necessity criteria including symptom duration ≤4 months, failed optimal medical therapy, specified indications, and required imaging.

SourceLink

POLICY UPDATE CHANGES

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

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

Added instruction to refer to the Idaho Medicaid Provider Handbook for additional information on non-covered and excluded services.

Updated Clinical Evidence and Supporting Information sections.

Idahostate to which this policy applies

4 monthssymptom duration window

22510-22515listed CPT codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

enumerated covered indications

06/01/2026policy revision date

Coverage and Medical Necessity Criteria

Medically Necessary Criteria

Covered when ALL of the following are met

Primary clinical criteria: Procedure is for pain causing Functional or Physical Impairment in cervical, thoracic, or lumbar vertebral bodies within 4 months of pain onset that has failed to respond to Optimal Medical Therapytime <= 4 months

Covered indications: 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; vertebral hemangioma with aggressive features; unstable fractures due to osteonecrosis (e.g., Kummel disease)

Required imaging and exclusion of other causes: Computed tomography (CT) or magnetic resonance imaging (MRI) has ruled out other causes of spinal pain (e.g., foraminal stenosis, herniated intervertebral disk, other significant coexistent spinal or bony pain generators)

Negative exclusion findings: None of the following are present: clinical evidence of spinal cord compression on CT/MRI; significant vertebral collapse or destruction (e.g., vertebra reduced to less than one-third original height); healed VCF; lesions of the sacrum or coccyx; asymptomatic VCFs; VCFs responding appropriately to conservative therapy

See related policy for sacral augmentation

Evidence-based coverage considerations

Coverage is supported selectively where clinical criteria are met based on the evidence presented in these sections.

Symptomatic OVCF with clinical correlation: Patient has an osteoporotic vertebral compression fracture with correlating signs and symptoms (localized pain and functional impairment) documented; conservative management has been attempted or considered and failed or the patient is a candidate for augmentation based on clinical judgmentsymptomatic VCF with clinical correlation

Supported by systematic reviews and meta-analyses showing benefit for symptomatic VCFs over conservative care.

Procedure selection evidence: Choice of vertebroplasty (PVP) versus kyphoplasty (PKP/BKP) may be guided by radiographic goals: kyphoplasty may provide better vertebral height restoration and lower cement leakage risk, while pain and disability outcomes are often similar between proceduresN/A

Comparative trials and HTA reports describe similar clinical outcomes but differences in radiographic results and resource use.

Covered indications supported by evidence summaries

Evidence-supported indications and comparative findings (study-level summaries):

Malignant vertebral compression fractures (metastatic disease): Systematic reviews and observational studies report clinically relevant improvements in pain, disability (ODI), and performance scores after PVP or PKP compared with baseline or usual care; cement leakage is common but rarely symptomatic

Sorensen et al. and other reviews report marked pain and functional improvements with reported cement leakage rates and low symptomatic complications.

Multiple myeloma with vertebral involvement: Retrospective studies and reviews report significant pain reduction and functional improvement after PVP/PKP, with shorter hospital stays versus more complex MISS procedures; cement leakage rates vary across series

Reinas et al., Nas et al., and Health Quality Ontario syntheses document consistent palliative benefit.

Symptomatic aggressive vertebral hemangioma: Case series and cohort studies report large and often complete pain relief with PVP, low symptomatic complication rates, and no procedural mortality in reported cohorts

Guideline-based indications and recommendations

Coverage considerations derived from guideline positions and evidence summaries in the document.

Guideline stance: Society recommendations vary: AAOS recommends against vertebroplasty for neurologically intact osteoporotic compression fractures and considers kyphoplasty an option; AACE/ACE do not recommend vertebral augmentation as first-line therapy; ACR endorses conservative management first-line and defines failure of conservative therapy; NASS (2024) gives a Grade A recommendation for vertebral augmentation in adults with acute OVCFs for rapid and sustained pain/function improvement

Multiple society positions are cited and should inform but not replace case-level clinical judgment.

ACR 'usually appropriate' indications

ACR appropriateness variants — usually appropriate when:

Appropriate scenarios: Symptomatic OVCF with bone marrow edema or intravertebral cleft; new symptomatic VCF with a history of prior vertebroplasty or surgery; benign VCF with worsening pain, deformity, or pulmonary dysfunction; pathological VCF with ongoing or increasing mechanical pain

These scenarios reflect ACR 'usually appropriate' variants for percutaneous vertebral augmentation.

Lesions of the sacrum or coccyx are excluded from coverage under this policy; for percutaneous sacral augmentation and related sacrococcygeal procedures, refer to the Medical Policy titled Minimally Invasive Spine Surgery Procedures (for Idaho Only) for applicability and coverage rules. Requests involving sacral or coccygeal lesions should be evaluated under that related policy before applying vertebral augmentation criteria in this document.

Randomized and systematic-review evidence does not support routine use of vertebroplasty for acute or subacute osteoporotic vertebral compression fractures in the absence of a clear, clinically correlated symptomatic benefit. Clinicians should inform patients that high- to moderate-quality evidence found no demonstrable clinically important benefit of vertebroplasty versus placebo (sham) and that the procedure has a potential for harm; coverage is reserved for patients who meet the policy's clinical criteria, including documented pain and functional impairment that correlate with the fractured level.

The body of evidence for vertebral augmentation across indications is heterogeneous in design and quality. For metastatic spinal lesions, systematic reviews report benefits for pain and function versus nonsurgical management but rate the certainty of evidence as low to very low for some endpoints. Users of this policy should account for that heterogeneity when applying coverage determinations and document the clinical rationale for treatment selection.

There is no indication to perform vertebral augmentation purely for prophylaxis against future vertebral fractures. Percutaneous vertebral augmentation is usually not appropriate for asymptomatic osteoporotic vertebral compression fractures; procedures should be reserved for symptomatic fractures with clinical correlation to imaging and failure of conservative therapy where applicable.

For information on non-covered or excluded services beyond what is listed in this policy, refer to the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers: Non‑Covered and Excluded Services. State or contract-specific exclusions described in that handbook may affect coverage determinations for Idaho members.

Percutaneous vertebroplasty and kyphoplasty are considered unproven and not medically necessary for indications other than those listed in this policy because current evidence does not demonstrate sufficient efficacy for off‑label or unlisted uses. Requests for augmentation outside the enumerated indications should be denied as not medically necessary unless supported by clear, contemporaneous clinical evidence meeting the policy criteria.

Chronic vertebral compression fractures that are identified radiographically but lack clinical correlation (i.e., no localized pain or functional impairment attributable to the imaged fracture) are not supported for vertebral augmentation. Systematic reviews and pooled analyses show no benefit of augmentation over nonoperative care for chronic radiographic‑only VCFs; therefore interventions in such cases are unlikely to meet medical necessity requirements.

Evidence quality varies by indication and outcome; for some endpoints—particularly functional outcomes and quality-of-life measures in metastatic vertebral disease—the certainty of evidence has been graded as low or very low. These limitations should be considered when evaluating expected benefit and counseling patients.

Guideline positions differ. The American Academy of Orthopaedic Surgeons (AAOS) recommends against vertebroplasty for neurologically intact osteoporotic compression fractures but considers kyphoplasty an option in selected patients. The American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) do not recommend vertebroplasty or kyphoplasty as first‑line therapy for vertebral fractures. These guideline contrasts inform but do not replace the policy's coverage criteria, which require documented clinical correlation and prior conservative management where applicable.

Coverage determinations made under this policy may be superseded by applicable federal, state, or contractual requirements. When such higher‑priority requirements differ from this policy, those requirements govern and should be applied in determining coverage for a particular member.

Applicable Codes and Coding Rules

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).

Applicable Codes / Non-covered instructionmixed

Refer to Idaho Medicaid Provider Handbook

Instruction to consult Idaho Medicaid Provider Handbook for additional information on non-covered and excluded services.

Symptom duration — eligibility window

Eligibility windowPain onset ≤ 4 months (procedure must be within 4 months of symptom onset)

Anatomic scopeCervical, thoracic, or lumbar vertebral bodies only

Therapy prerequisitePain must have failed to respond to Optimal Medical Therapy prior to consideration

Provider Requirements, Prior Authorization, and Documentation

Documentation Required

Documentation Required and Clinical Exclusion Triggers for Denial

Benefit coverage is determined by federal, state, and contractual requirements; medical records may be requested to confirm that the member meets clinical criteria. The patient's medical record must contain legible documentation that fully supports medical necessity, including but not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests (e.g., CT or MRI). Lack of required imaging or clinical documentation (history, exam, symptom correlation, or prior conservative therapy) may result in denial of coverage.

Required documentation: history of present illness documenting pain onset and severity, physical exam correlating pain to the index vertebral level, CT or MRI ruling out alternative spinal pain generators, and documentation of conservative therapy and its failure.
Clinical exclusion triggers for denial: absence of imaging correlating symptoms to the fracture, healed VCF on imaging, evidence of spinal cord compression, severe vertebral body collapse (< one-third original height), asymptomatic VCF, lesions limited to sacrum/coccyx per related policy, or documentation showing adequate response to conservative therapy.

Background and Scope

Percutaneous vertebroplasty injects polymethylmethacrylate (bone cement) into a fractured vertebral body to stabilize the fracture and relieve pain; kyphoplasty uses an inflatable bone tamp (balloon) prior to cement injection to attempt restoration of vertebral height and reduction of kyphotic deformity. Both are image‑guided, minimally invasive procedures intended primarily for symptomatic osteoporotic or lytic pathologic fractures that have not responded to conservative care or when rapid pain relief is required for palliation.

Key Definitions

Functional or Physical Impairment — definition

Core definitionDeviation from normal function of a tissue or organ resulting in significantly limited or delayed capacity to move, coordinate actions, or perform physical activities

ManifestationsDifficulties with physical/motor tasks, independent movement, or performance of basic life functions

Policy useRequired clinical state for vertebral augmentation: pain causing Functional or Physical Impairment constitutes a covered indication when other criteria are met

Optimal Medical Therapy — definition

Core definitionTreatments used as first-line before moving to more invasive, risky, or complex procedures

Examples (contextual)

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty and Kyphoplasty (for Idaho Only)

Policy CodePolicy CS330ID.C

Change TypeRevisions to imaging exclusion examples and updated definitions

Effective DateJun 1, 2026

Next Review Date

SourceLink

On This Page

Oncologic and palliative indications: For osteolytic metastatic lesions and multiple myeloma involving a vertebral body, PVP/PKP can provide palliative pain relief and functional benefit; device selection and adjunctive techniques (e.g., combined ablation, radiotherapy) depend on lesion characteristics and goals of carepalliative intent

Supported by systematic reviews and multiple observational series reporting pain and functional improvements.

Nambiar, Narayana, Hao and Hu, and Boschi series demonstrate rapid and durable pain relief.

Kümmell disease (osteonecrosis, unstable fractures): Multiple retrospective studies and meta-analyses indicate both PKP and PVP relieve pain; PKP commonly provides better radiographic correction (vertebral height, kyphotic angle) and lower cement leakage but with greater operative resources; clinical pain outcomes are often similar

Li, Wang, Zhang, Dai and others report comparative radiographic and clinical results.

Denial Risk

Potential Clinical Ineffectiveness and Harm

Vertebral augmentation may be clinically ineffective or harmful if performed without clinical correlation between imaging and symptoms or before adequate conservative management has failed. Systematic reviews and RCT evidence show little to no benefit of vertebroplasty compared with sham for some OVCFs and emphasize informing patients about limited benefit and potential harms.

Potential ineffectiveness: vertebroplasty has high- to moderate-quality evidence showing no demonstrable clinically important benefit versus placebo for some osteoporotic VCFs.
Clinical harm: documented risks include cement leakage (frequent, often asymptomatic), and reports of serious adverse events following vertebroplasty; therefore procedures should be limited to patients meeting coverage criteria with symptom–imaging concordance.

Note

Adverse Events and Cement-related Risks

Major adverse events following vertebroplasty or kyphoplasty are uncommon in the literature, though cement leakage is common and often asymptomatic. Procedure-related complications reported across studies include additional VCFs and, less frequently, pulmonary embolism, DVT, pneumonia, or other serious events; most large series and prospective studies report low rates of major complications when patient selection and technique follow standards.

Cement leakage: commonly reported across studies; usually asymptomatic but should be documented when present.
Major adverse events: uncommon overall in kyphoplasty and vertebroplasty series, but have been reported (e.g., pulmonary embolism, myocardial infarction, infection); monitor and document any device- or procedure-related adverse events.

Note

Conflict With Higher-Priority Coverage Requirements

Verify and follow any higher-priority benefit or contractual rules (federal, state, or plan-specific) before applying this policy. Where federal or state law, Medicaid program rules, or specific plan/contract provisions differ from this policy, those requirements govern coverage determinations.

Idaho-specific applicability: this policy applies to Idaho (including Idaho Medicaid Plus); however, check plan/contract terms for prior authorization or coverage exceptions.
Refer to Idaho Medicaid Provider Handbook for non-covered/excluded services and any plan-specific documentation or prior authorization instructions.

Prior Authorization

Failure of Conservative Therapy and Therapy Sequencing

Percutaneous vertebral augmentation should generally be offered only after an adequate trial of conservative (nonoperative) therapy has failed. The ACR defines failure of conservative therapy as pain refractory to oral medications (NSAIDs and/or narcotics), contraindication to such medications, or requirement for parenteral narcotics and hospital admission. Document the conservative management provided and objective evidence of failure before authorization or scheduling.

Documented failure of conservative therapy must include treatment dates, modalities attempted (e.g., analgesics, bracing, activity modification, physical therapy), response to each, and rationale for proceeding to augmentation.
Therapy sequencing: nonoperative management is first-line for painful VCFs; vertebral augmentation is reserved for patients with refractory symptomatic fractures, those with bone marrow edema or intravertebral cleft on imaging, or other indications listed in coverage criteria.

Conservative medical management including oral analgesics and immobilization as initial therapy for VCFs per ACR guidance

Policy requirementOptimal Medical Therapy must be attempted and failed prior to considering vertebral augmentation

Osteonecrosis — definition (Kümmell disease noted)

Core definitionBone death (avascular/aseptic necrosis) due to reduced blood flow to bone, also referred to as Kummel disease in vertebral collapse contexts

Causes and risk factorsSteroid medications, alcohol use, injury, increased intraosseous pressure, radiation, chemotherapy, organ transplants

Clinical relevanceUnstable fractures due to osteonecrosis (e.g., Kummel disease) are a listed covered indication for augmentation when other criteria met

Vertebral Hemangiomas — definition and characteristics

Core definitionBenign vascular tumors of the bony spine that are usually asymptomatic

Aggressive featuresExtraosseous extension, bone expansion, disturbance of blood flow, and occasional compression fractures (most often T3–T9)

Policy implicationVertebral hemangioma with aggressive features is a covered indication when causing pain and meeting imaging/clinical criteria

SpineJack — device definition and context

Device descriptionAn expandable titanium implant used with cement augmentation to restore vertebral body height and correct kyphosis (commercially known as SpineJack®)

Comparative contextIn a pilot randomized study SpineJack achieved better vertebral height restoration and kyphosis correction than BKP while both improved pain and function

Use caseDevice is used in vertebral augmentation procedures for OVCFs where radiographic height restoration is an objective

OVCF — definition and clinical correlation

DefinitionOsteoporotic vertebral compression fracture (OVCF): fracture of a vertebral body due to osteoporosis presenting with pain and potential functional impairment

Clinical correlationProcedure selection requires documented symptomatic correlation (localized pain, functional impairment) and imaging evidence; asymptomatic or radiographic-only chronic VCFs are not supported

Evidence noteSystematic reviews/meta-analyses report improvements in pain with vertebral augmentation versus conservative care in selected symptomatic OVCFs

PVP / PKP — definitions

PVPPercutaneous vertebroplasty (PVP): image-guided percutaneous injection of bone cement (PMMA) into a fractured vertebral body to stabilize the fracture and relieve pain

PKPBalloon kyphoplasty (PKP/BKP): image-guided procedure using an inflatable bone tamp to create a cavity and restore vertebral height before cement injection; may reduce kyphotic deformity and cement leakage compared with PVP

Clinical outcomesBoth PVP and PKP have been reported to provide rapid pain relief; PKP often achieves superior radiographic correction in some series

Kümmell disease (stage III) — definition

Kümmell disease (stage III)An osteonecrotic vertebral collapse characterized by intravertebral vacuum cleft and progressive collapse; stage III indicates advanced collapse often without neurological deficit in cited studies

Clinical managementPVP and PKP have been used to treat stage III Kümmell disease; PKP may provide better radiographic restoration and lower cement leakage in some studies

Study contextRetrospective comparisons report improved radiographic parameters and similar or better pain/ODI outcomes with PKP versus PVP in stage III Kümmell disease

Failure of conservative therapy — definition and examples

Core definitionFailure of conservative therapy: pain refractory to oral medications (NSAIDs and/or narcotics), contraindication to such medications, or requirement for parenteral narcotics and hospital admission

ExamplesInsufficient pain relief with oral analgesics and immobilization, inability to tolerate medications, or need for inpatient/parenteral analgesia

Policy roleDocumented failure of conservative/optimal medical therapy is required prior to considering vertebral augmentation per policy and guideline guidance

Symptomatic OVCF with bone marrow edema or intravertebral cleft — definition

Required imaging correlateSymptomatic OVCF demonstrating bone marrow edema or an intravertebral cleft on MRI or CT (imaging demonstrating acute/subacute change)

Clinical correlateFracture must be symptomatic with localized pain and functional impairment documented in the medical record

ACR stanceACR lists symptomatic OVCF with bone marrow edema or intravertebral cleft as a 'usually appropriate' indication for vertebral augmentation

Functional or Physical Impairment (updated definition)

Updated core definitionFunctional or Physical Impairment: deviation from normal tissue or organ function causing significant limitations in movement, coordination, or basic physical activities

Clinical examplesDifficulties with physical/motor tasks, independent movement, or performing basic life functions as documented in the medical record

Policy applicationUpdated definition applied to coverage criteria: pain must cause Functional or Physical Impairment to qualify for augmentation

Optimal Medical Therapy (updated definition)

Updated definition summaryOptimal Medical Therapy: first-line treatments used before invasive procedures; definition revised in this policy update

ExpectationThese therapies should be attempted and documented as failed before vertebral augmentation is considered

Guideline alignmentConsistent with ACR and other guideline recommendations that conservative management is initial therapy for VCFs

Osteonecrosis (updated definition)

Updated definitionOsteonecrosis: disease caused by reduced blood flow to bone (also referred to as Kummel disease in vertebral collapse), with nonsurgical treatments providing short-term pain relief but not cure

Policy noteUpdated definition emphasizes Kummel disease as an example of unstable osteonecrotic fractures considered for augmentation when criteria met

Risk factorsSteroids, alcohol, injury, increased intraosseous pressure, radiation, chemotherapy, organ transplant history

Vertebral Hemangiomas (updated definition)

Updated definitionVertebral Hemangiomas: benign vascular spine tumors usually asymptomatic; updated definition retains aggressive subset features such as extraosseous extension and bone expansion

Typical locationAggressive vertebral hemangiomas most often occur between T3 and T9

Coverage implicationAggressive vertebral hemangiomas causing pain and meeting imaging/clinical criteria are a covered indication