CurrentUnitedHealthcarePolicy CS330KY.10

Percutaneous Vertebroplasty and Kyphoplasty (for Kentucky Only)

Policy governs medical necessity and coverage considerations for percutaneous vertebroplasty and kyphoplasty for members in Kentucky; it applies to providers and claims adjudication for UnitedHealthcare benefit plans where state or contractual requirements permit.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty and Kyphoplasty (for Kentucky Only)

Policy CodePolicy CS330KY.10

Change TypeDocumentation clarification (material)

Effective Date05/01/2026

Next Review Date

Key ActionEnsure the patient medical record fully documents medical necessity and make records available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews section added language clarifying documentation expectations to support medical necessity.

Kentucky-onlystate application

InterQualclinical criteria source

CPT 22510-22515referenced procedure codes

05/01/2026effective date

Coverage Criteria for Vertebroplasty and Kyphoplasty

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Covered with criteria

Covered when ALL of the following are met:

InterQual criteria: Member meets InterQual CP: Procedures, Vertebroplasty or Kyphoplasty medical necessity criteria

UnitedHealthcare uses InterQual as the primary medical/surgical criteria source; if InterQual is not applicable, UnitedHealthcare may reference applicable UnitedHealthcare medical policies, coverage determination guidelines, or utilization review guidelines as permitted by state or contractual requirements.

The UnitedHealthcare policy notes that percutaneous vertebroplasty and kyphoplasty are procedures and are not regulated by the FDA. However, certain component devices used during these procedures—specifically some bone cement products and bone tamps—have FDA classifications (generally Class II) and FDA marketing authorizations. Information about specific cleared products and their FDA product codes is available from the FDA device databases.

This policy does not enumerate specific scenarios labeled as not medically necessary. Instead, coverage determinations for vertebroplasty and kyphoplasty are made by applying the InterQual CP: Procedures, Vertebroplasty or Kyphoplasty medical necessity criteria; providers and adjudicators should refer to InterQual when evaluating whether a proposed procedure meets clinical coverage standards.

Applicable Procedure Codes

Applicable CPT CodesCPT

22510

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

Applicable CPT CodesCPT

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)

Provider Requirements and Actions

Prior Authorization

InterQual-based prior authorization

Coverage determinations must meet InterQual® CP: Procedures, Vertebroplasty or Kyphoplasty criteria. Prior authorization is based on those InterQual criteria and services not meeting the InterQual requirements may be denied.

Note

Provider action summary

Action required: Submit a complete prior authorization request and ensure all supporting medical records are available. Failure to request authorization when required or to provide necessary documentation may result in denial or delay of payment.

Documentation Required

Required medical records

The patient's medical record must contain documentation that fully supports medical necessity for the requested vertebroplasty or kyphoplasty. Required elements include, but are not limited to, relevant medical history, focused physical examination, diagnostic imaging/results (e.g., radiographs, CT, MRI), documentation of symptoms and functional impairment, prior conservative treatment attempts and duration, and procedure-specific operative planning notes.

Relevant medical history and focused physical exam
Pertinent diagnostic test results and imaging (radiographs, CT, MRI)
Documentation of symptoms, functional limitation, and pain severity
Records of prior conservative therapy and duration (medication, physical therapy, injections)
Prior authorization request and justification, if applicable
Operative planning notes and informed consent documentation

Denial Risk

Documentation-driven denial risk

Lack of sufficient documentation to demonstrate that InterQual criteria are met or failure to produce medical records upon request may result in denial of the request or retrospective denial of payment. Maintain legible records and make them available for review.

Background

Percutaneous vertebroplasty and kyphoplasty are minimally invasive vertebral augmentation procedures used to treat selected vertebral compression fractures. Vertebroplasty involves percutaneous injection of bone cement into a vertebral body to stabilize the fracture and reduce pain. Kyphoplasty includes creation of a cavity (for example, with a balloon tamp) followed by cement placement to restore vertebral body height and provide stabilization. These procedures often use implantable bone cement materials (such as PMMA) and may employ bone tamps—components that have separate FDA device classifications even though the procedures themselves are not FDA-regulated.

Definitions

Vertebroplasty / Kyphoplasty — definitions

Percutaneous vertebroplastyCement injection into a vertebral body to stabilize compression fractures; procedure codes include CPT 22511 with additional-unit code 22512 for extra vertebral bodies.

Percutaneous vertebral augmentation (kyphoplasty)Augmentation that includes cavity creation (e.g., balloon or mechanical device) and cement placement to reduce fracture and stabilize the vertebra; primary codes include CPT 22513 (thoracic) and 22514 (lumbar) with add-on code 22515 for each additional level.

Imaging guidanceBoth vertebroplasty and kyphoplasty are performed inclusive of all imaging guidance as described in the CPT code definitions.

PMMA bone cement — definition and FDA classification

PMMA bone cement — compositionPolymethyl methacrylate (PMMA) bone cement is an implantable device made from methyl methacrylate, PMMA, esters of methacrylic acid, or copolymers containing PMMA and polystyrene.

Intended useThese bone cement products are intended for use in arthroplastic procedures and for fixation of prosthetic implants to living bone; they are used with vertebral augmentation procedures such as kyphoplasty when cleared for that use.

FDA classificationPMMA bone cements are marketed as FDA-regulated implantable devices; related component devices (bone tamps) are categorized as Class II devices by the FDA.