ModifiedUnitedHealthcarePolicy CSNCT0581.04

Percutaneous Vertebroplasty and Kyphoplasty (for North Carolina Only)

Clinical coverage policy for percutaneous vertebroplasty and kyphoplasty in North Carolina; defines indications, required imaging exclusions, and documentation expectations for UnitedHealthcare members and their providers.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty and Kyphoplasty (for North Carolina Only)

Policy CodePolicy CSNCT0581.04

Change TypeDefinitions updatedimaging-exclusion examples reviseddocumentation clarified

Effective DateJun 1, 2026

Next Review Date

Key ActionDocument a trial of optimal medical therapy and include history, physical exam, and CT/MRI that rules out other causes of spinal pain when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

Revised list of examples of causes of spinal pain to be ruled out by computed tomography (CT) or magnetic resonance imaging (MRI).

Removed 'Facet arthropathy' and 'Other spinal degenerative disease' from the list of examples of causes of spinal pain to be ruled out by CT or MRI.

Added requirement that the patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including history, physical exam, and results of pertinent diagnostic tests or procedures.

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

Updated Clinical Evidence and References sections to reflect the most current information.

6+listed indications for coverage

<=4mtimeframe from pain onset for coverage

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.

Coverage Criteria and Clinical Indications

Medical necessity coverage 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 Therapytimeframe <= 4 months; failed Optimal Medical Therapy

Includes pain causing functional/physical impairment

Covered etiologies: 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., Kummell disease)one of listed etiologies

Must be a listed etiology

Imaging and diagnostic exclusions: CT or MRI has ruled out other causes of spinal pain (for example foraminal stenosis, herniated intervertebral disk, or other significant coexistent spinal or bony pain generators) AND CT/MRI do not show clinical evidence of spinal cord compression, significant vertebral collapse or destruction (vertebra reduced to less than one-third of its original height), a healed VCF, or lesions of the sacrum or coccyximaging confirming absence of excluded findings

Imaging required to confirm eligibility

Coverage considerations

Evidence-based coverage considerations for OVCFs and metastatic vertebral disease

Symptomatic OVCF with clinical correlation: Percutaneous vertebral augmentation (PVP/PKP) may provide greater pain relief than conservative management for symptomatic osteoporotic vertebral compression fractures with correlating signs/symptoms in several systematic reviews and meta-analyses; benefits are most evident when clinical correlation is present.symptomatic with clinical correlation

Supported by Hayes HTA updates and Pourtaheri et al. meta-analysis

Vertebroplasty vs sham evidence: High-quality randomized placebo-controlled trials and a Cochrane review found no demonstrable clinically important benefit of vertebroplasty compared with sham for acute or subacute osteoporotic VCFs; this evidence should be considered when selecting PVP.RCT/sham comparison

Buchbinder et al. Cochrane review concluded no important benefit and potential harms

Kyphoplasty potential benefit:

Evidence-supported indications and comparative findings

Evidence-based findings relevant to coverage decisions

Indications supported by evidence: PVP or PKP provide rapid and significant pain relief and improved function in patients with painful vertebral compression fractures due to metastatic disease, multiple myeloma, and symptomatic vertebral hemangioma; these procedures are considered palliative and effective in these populations.

Supported by systematic reviews, meta-analyses, RCTs, and case series

Kummell disease considerations: For neurologically intact osteoporotic Kummell disease, PKP often achieves better kyphosis correction and lower cement leakage than PVP while both yield similar pain and ODI outcomes; choice should balance radiographic goals against resource use.

Supported by comparative studies and network meta-analyses

Safety considerations: Cement leakage is a common finding (reported rates vary; e.g., 37.9% for PVP vs 13.6% for PKP in malignant VCF reviews); symptomatic complications are uncommon. PKP tends to have lower leakage rates but greater cement volume, operative time, fluoroscopy, and cost.

See systematic reviews and cohort data for leakage and complication rates

Medically necessary indications for vertebral augmentation

Vertebral augmentation (PVP or PKP) is considered medically reasonable and necessary when:

Primary eligibility

Conservative therapy: Failure of conservative therapy (pain refractory to oral medications or requirement for parenteral narcotics/hospital admission) OR contraindication to such medications
Failure of conservative therapy per policy definitions
Clinical severity: Severe ongoing pain despite optimal pain management that significantly alters quality of life
Consistent with NICE criteria: severe ongoing pain with exam/imaging confirmation

Selection notes: Procedure may be more appropriate earlier after fracture for better outcomes; kyphoplasty may provide better vertebral height restoration and lower cement leakage but similar pain/function outcomes compared with vertebroplasty

Reflects evidence favoring earlier intervention and PKP radiographic advantages

Not medically necessary / usually not appropriate

Not routinely covered:

Asymptomatic fractures: Asymptomatic osteoporotic vertebral compression fractures

Listed as usually not appropriate by ACR and policy exclusions

Routine vertebroplasty for neurologically intact OVCFs: Vertebroplasty for neurologically intact, osteoporotic spinal compression fractures is not recommended by the AAOS and is considered not medically necessary when used routinely for these patients

AAOS strong recommendation against vertebroplasty in neurologically intact OVCFs

The following findings on CT or MRI are exclusionary for vertebral augmentation: clinical evidence of spinal cord compression, significant vertebral collapse or destruction (for example, vertebra reduced to less than one-third of its original height), healed vertebral compression fracture (VCF), lesions of the sacrum or coccyx, asymptomatic VCFs, and VCFs responding appropriately to conservative therapy. Procedures requested for indications outside those listed in the policy are considered unproven and not medically necessary due to insufficient evidence of efficacy.

Randomized, placebo-controlled trials and an updated Cochrane review do not demonstrate clinically important benefit of vertebroplasty compared with sham for acute or subacute osteoporotic VCFs; the review concluded there was no demonstrable benefit and noted potential harms and serious adverse events. This limitation in high-quality evidence is a key consideration when assessing requests for routine vertebroplasty in acute/subacute osteoporotic fractures.

The available literature is heterogeneous across indications and study designs; systematic reviews and observational series report variable effect sizes and quality of evidence for metastatic, myeloma-related, and other pathologic VCFs. While some analyses show benefit for pain and function in cancer-related fractures, low-quality evidence, small trial sizes, and diversity of interventions limit generalizability. The document highlights these limitations but does not list additional explicit procedural exclusions beyond those specified in imaging and clinical criteria.

Vertebral augmentation is not indicated as prophylaxis to prevent future vertebral fractures. The policy notes that use of percutaneous vertebroplasty or kyphoplasty for prophylaxis against future fracture is not an approved or supported indication.

The policy revision updated the list of examples of spinal pain causes to be ruled out by CT or MRI and removed specific examples previously listed (including Facet arthropathy and Other spinal degenerative disease). The update also clarified documentation expectations, requiring that the patient’s medical record fully support medical necessity with relevant history, physical examination, and results of pertinent diagnostic tests or procedures.

Percutaneous vertebroplasty and kyphoplasty are considered unproven and not medically necessary for indications other than those explicitly listed in the policy. Requests for these procedures that do not meet the stated clinical and imaging criteria should be considered unsupported by the evidence presented in this document.

Routine vertebroplasty for acute or subacute osteoporotic VCFs is not supported by high-quality sham-controlled evidence and therefore is not generally supported unless other specific selection criteria and indications apply. Where sham-controlled trials show no benefit, vertebroplasty requested without clear clinical correlation and appropriate selection may be considered not medically necessary.

Some comparative and pooled analyses include small trials or observational series with methodological limitations; the policy notes that evidence quality is low in certain comparisons (for example metastatic disease comparisons), which reduces certainty about relative benefits and harms and should inform individualized coverage decisions.

Professional guideline positions vary: the AAOS recommends against vertebroplasty for neurologically intact osteoporotic compression fractures based on sham-controlled trials, while AAOS considers kyphoplasty an option in selected patients. The ACR and NICE guidance emphasize that vertebral augmentation is usually appropriate for symptomatic osteoporotic VCFs with imaging correlation (for example bone marrow edema or intravertebral cleft) and that procedures should be reserved for patients with severe ongoing pain after optimal management with exam and imaging confirmation.

Procedure and Product 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.
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).

Procedure codes (referenced procedures)mixed

CPT unspecified in this excerpt

Policy text references kyphoplasty and vertebroplasty procedures; exact CPT/HCPCS codes are given elsewhere in the full policy.

No explicit CPT/HCPCS/ICD codes listed in this document segmentmixed

No codes listed

FDA device product codes (informational)mixed

NDN, LOD

FDA product codes referenced for bone cement PMMA products (informational).

FDA device product codes for bone tamps (informational)mixed

HRX, HXG

FDA product codes referenced for bone tamps used in balloon kyphoplasty (informational).

inv-20: Hounsfield unit (HU) value — lower HU associated with increased risk of new VCF after PVP/PKP

Hounsfield unit (HU) associationLower HU value is an independent risk factor for new vertebral compression fracture after PVP or PKP (multivariate OR = 0.963 per unit; 95% CI 0.943–0.984; p = 0.001)

Study populationRetrospective cohort of 247 patients undergoing PVP or PKP with 9.3% experiencing new VCFs

Relevant covariates analyzedAge, BMI, fracture location, surgical method, cement volume/leakage, preoperative compression, bisphosphonate use

inv-21: Body mass index (BMI) — lower BMI associated with worse outcomes and higher subsequent OVCF risk

BMI and outcomesLow BMI was identified as an independent predictor of poorer functional outcome and higher risk of subsequent OVCF after balloon kyphoplasty (multivariable OR 1.415; 95% CI 1.06–1.87; p = 0.046)

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior Authorization: Diagnosis and Clinical Severity

Prior authorization is required for percutaneous vertebroplasty and kyphoplasty. Requests must document the diagnosis and clinical severity of the vertebral compression fracture (VCF), including baseline pain scores (e.g., VAS/NRS), functional impact, and objective correlation of pain to the fractured vertebral level(s) on imaging (CT or MRI).

Prior authorization required prior to scheduling augmentation procedures.
Include pain severity (baseline VAS/NRS), duration of symptoms, and functional limitation description.

Prior Authorization

Conservative Therapy Failure Required

Conservative therapy (Optimal Medical Therapy) must have been tried and failed unless there is a documented contraindication. Optimal Medical Therapy includes appropriate first-line medical management (e.g., NSAIDs, oral opioids when indicated), activity modification, and immobilization when appropriate. Failure is defined as pain refractory to oral medications or a need for parenteral narcotics/hospital admission per ACR definitions.

Document trial of Optimal Medical Therapy and reason(s) for insufficient response.

Clinical Background and Context

Percutaneous vertebroplasty involves image‑guided injection of bone cement into a fractured vertebral body to stabilize the fracture and relieve pain. Kyphoplasty uses a balloon or bone tamp to restore some vertebral height before cement placement; both procedures are performed percutaneously under imaging guidance and are intended to provide rapid pain relief and functional improvement in selected patients with symptomatic osteoporotic or pathologic VCFs.

Definitions and Terms

inv-44: Functional or Physical Impairment — definition summary

DefinitionFunctional or Physical Impairment: deviation from normal tissue/organ function causing a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities

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

Clinical relevanceUsed as a coverage criterion when pain from a vertebral fracture causes substantial limitation in daily activities

inv-45: Optimal Medical Therapy — definition summary

DefinitionOptimal Medical Therapy: treatments used as first-line management before progressing to more invasive, risky, or complex procedures

Examples (scope)

Policy Revision History

2026-06-01policy_revisionLatest

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'); expanded medical records documentation requirements; updated definitions for Functional or Physical Impairment, Optimal Medical Therapy, Osteonecrosis, and Vertebral Hemangiomas; updated Clinical Evidence and References.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty and Kyphoplasty (for North Carolina Only)

Policy CodePolicy CSNCT0581.04

Change TypeDefinitions updatedimaging-exclusion examples reviseddocumentation clarified

Effective DateJun 1, 2026

Next Review Date

Key ActionDocument a trial of optimal medical therapy and include history, physical exam, and CT/MRI that rules out other causes of spinal pain when requesting prior authorization.

SourceLink

On This Page

Note

Check Benefit Requirements and Utilization Tools

Before approving services, check member-specific benefit coverage, applicable federal/state/contractual requirements, and use UnitedHealthcare utilization management tools (including any proprietary criteria such as InterQual®) to verify prior authorization and coverage rules.

Verify plan benefits and any state mandates affecting coverage.
Use UnitedHealthcare prior authorization portal and clinical decision tools as required.

Denial Risk

Efficacy Limitations May Trigger Denials

Evidence has limitations that may lead to denial when documentation does not support likely benefit. Randomized and systematic reviews have found mixed results for vertebroplasty compared with sham or conservative care for some indications; in some analyses no clinically important benefit was demonstrated. Requests lacking clear clinical correlation, objective imaging concordance, or adequate trial of conservative care may be denied.

Be aware that vertebroplasty has mixed evidence versus sham in some RCTs and systematic reviews.
Document why the individual is expected to derive clinically meaningful benefit given the evidence limitations.

Denial Risk

Clinical Indication and Safety Documentation

Clinical indications and safety concerns must be explicitly addressed in the records. Exclusionary findings that should be absent include clinical or imaging evidence of spinal cord compression, significant vertebral destruction (e.g., vertebra reduced to <1/3 original height), healed fractures, lesions of sacrum/coccyx, asymptomatic fractures, or fractures responding to conservative therapy. For oncologic indications, document tumor involvement and goals of care (palliation vs structural stabilization).

Document CT or MRI ruling out alternative pain generators (foraminal stenosis, herniated disk, other bony/spinal pain sources).
Document absence of spinal cord compression and degree of vertebral height loss on imaging.

Documentation Required

Required Documentation

Medical records must fully support medical necessity for the requested procedure. Include relevant history, focused physical exam, baseline pain and function scores, prior non-surgical management, and results of pertinent diagnostic imaging (CT or MRI). Records should be legible, maintained in the medical record, and available on request.

Include baseline VAS/NRS and functional measures (e.g., ODI, Karnofsky) when available.
Attach imaging reports and images confirming the level(s) treated and correlating bone marrow edema or intravertebral cleft when applicable.

Documentation Required

Failure of Conservative Therapy and Localization

Documentation should clearly show failure of conservative therapy or a documented contraindication to conservative measures, and localize the pain to the treated fracture level(s). For new symptomatic OVCFs, provide imaging evidence of acuity (bone marrow edema or intravertebral cleft) and clinical correlation of pain to that level.

For symptomatic OVCF, document bone marrow edema on MRI or intravertebral cleft on imaging when available.
If pain onset is >4 months without correlation to imaging or if conservative therapy is effective, the request may be denied.

Prior Authorization

Conservative Therapy Prerequisite and Prior Non-surgical Management

Document prior non-surgical management and that nonoperative medical therapy did not provide adequate pain relief. Conservative management (medical management with or without immobilization) is first-line; augmentation is considered when these measures fail or are contraindicated.

List medications tried (doses/dates), duration of conservative measures, physical therapy, bracing, and any reasons for intolerance or contraindication.
Note any prior vertebroplasty/surgery at the same level if applicable.

inv-48: Kyphoplasty (BKP) — definition and description

Definition/techniqueKyphoplasty (BKP): a balloon-assisted percutaneous vertebral augmentation in which an inflatable bone tamp is used to restore vertebral height and create a cavity that is then filled with bone cement

Clinical effectsMay provide pain relief and radiographic restoration of vertebral height; some evidence suggests improved kyphosis correction versus vertebroplasty

Comparative considerationsAssociated with longer operative time, higher cost, and greater cement volume but typically lower cement leakage rates compared with PVP

inv-51: Failure of conservative therapy — definition summary

DefinitionFailure of conservative therapy: pain refractory to oral medications (NSAIDs and/or narcotics), contraindication to such medications, or requirement for parenteral narcotics or hospitalization

Policy implicationConservative management is first-line; percutaneous vertebral augmentation is considered after failure of nonoperative measures

Documentation neededRecords should document trial of Optimal Medical Therapy and that pain significantly alters quality of life despite conservative care