ModifiedUnitedHealthcarePolicy CS330NJ.F

Percutaneous Vertebroplasty and Kyphoplasty (for New Jersey Only)

Defines medical necessity and coverage criteria for percutaneous vertebroplasty and kyphoplasty for New Jersey members, including applicable indications and required diagnostic evaluation.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty and Kyphoplasty (for New Jersey Only)

Policy CodePolicy CS330NJ.F

Change TypeUpdates to imaging differentials, definitions, and documentation expectations

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document failure of optimal conservative therapy, symptomatic fracture within 4 months, and CT/MRI exclusion of other spinal pain generators.

SourceLink

POLICY UPDATE CHANGES

Added reference link to the Medical Policy titled Minimally Invasive Spine Surgery Procedures (for New Jersey Only).

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.

Added language clarifying that benefit coverage is subject to federal, state, or contractual requirements and that medical record documentation may be required to assess clinical criteria but does not guarantee coverage.

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.

4 monthsmax time from pain onset

6+covered indications

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CPT 22510-22515procedure codes referenced

~30+references cited

Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ALL of the following are met

Overall coverage conditions: Procedure is for treating pain causing Functional or Physical Impairment in cervical, thoracic, or lumbar vertebral bodies within 4 months of pain onset<= 4 months

From Coverage Rationale: symptom duration requirement

Conservative management requirement: Fracture pain has failed to respond to Optimal Medical Therapy (conservative/nonoperative management) unless contraindicateddocumented failure of conservative therapy

Optimal Medical Therapy prerequisite as stated in Coverage Rationale

Indication (one required): Procedure is for one of the listed indications: osteoporotic vertebral compression fracture, steroid-induced vertebral fracture, osteolytic metastatic disease involving a vertebral body, multiple myeloma involving a vertebral body, vertebral hemangioma with aggressive features, or unstable fractures due to osteonecrosis (e.g., Kummel disease)one required

List of covered indications from Coverage Rationale

Imaging and exclusion criteria: CT or MRI has ruled out other causes of spinal pain (e.g., foraminal stenosis, herniated disk, other significant spinal/bony pain generators) AND none of the following are present: clinical evidence of spinal cord compression; significant vertebral collapse/destruction (vertebra reduced to < one-third original height); healed VCF; lesions of the sacrum or coccyx; asymptomatic VCFs; VCFs responding to conservative therapyall required

Imaging requirements and exclusions per Coverage Rationale and exclusions list

Evidence-aligned coverage criteria (partial)

Coverage more likely when ALL of the following evidence-supported conditions are met:

Clinical correlation: Patient has a symptomatic vertebral compression fracture with clinical signs/symptoms that correlate with imaging findingsclinical and imaging correlation required

Supported by systematic reviews showing benefit when clinical correlation is present

Documented failure of conservative care: Inadequate response to an adequate trial of conservative, nonoperative management (unless contraindicated or in urgent/palliative contexts)documented trial of conservative therapy

Hayes and meta-analyses report benefit in selected individuals who have not responded to conservative therapy

Fracture acuity: Acute or subacute symptomatic fractures (evidence shows greater benefit in acute/subacute vs chronic radiographic-only fractures)

Evidence summaries by indication

Evidence summaries by indication (no prescriptive AND/OR coverage logic present in these chunks):

Osteolytic metastatic disease: Systematic reviews and trials report that PVP and PKP provide clinically relevant pain reduction, improved disability and performance scores, and quality-of-life gains in malignant VCFs; cement leakage is common but rarely symptomatic; some low-to-moderate quality evidence suggests BKP may improve radiographic outcomes

Sources: Astur/Aanzi, Sorensen, Sadeghi-Naini, Qi (chunks 36-39)

Multiple myeloma: Retrospective studies and case series show rapid pain reduction, decreased analgesic use, improved function, short hospital stays after PVP/PKP; cement leakage rates reported but symptomatic complications uncommon; evidence largely observational

Sources: Reinas, Nas, Health Quality Ontario (chunks 40-41)

Vertebral hemangioma with aggressive features: Case series and retrospective cohorts report substantial and sustained pain relief after PVP with low rates of symptomatic complications; studies are small and nonrandomized

Sources: Nambiar, Narayana (chunk 43 and related)

Medical necessity for vertebral augmentation

Covered when ALL of the following are met

Primary eligibility: Patient has a symptomatic osteoporotic or neoplastic vertebral compression fracture with pain localized to the fracture level confirmed by physical exam and imaging (e.g., bone marrow edema or intravertebral cleft)

Imaging examples supportive of augmentation per ACR/clinical guidance

Failure of conservative therapy: Severe ongoing pain despite optimal conservative pain management, or conservative therapy is contraindicated or has required parenteral narcotics/hospital admissiondocumented refractory pain or contraindication

Definition of failure of conservative therapy and prerequisites for augmentation

Guideline context: Consideration for augmentation should follow specialty guidance: NASS recommends augmentation for acute OVCFs (Grade A); AAOS recommends against vertebroplasty and considers kyphoplasty an option; NICE limits PVP/BKP to severe ongoing pain after recent unhealed fracture despite optimal pain management

Policy updates and evidence basis

Coverage decisions are based on the policy's clinical criteria and applicable federal, state, or contractual requirements.

policy_updates: Clinical Evidence and References sections were updated; definitions for Functional or Physical Impairment, Optimal Medical Therapy, Osteonecrosis, and Vertebral Hemangiomas were revised; examples of causes of spinal pain to be ruled out by CT/MRI were revised

Policy history and revision information

The following clinical findings or conditions are contraindications and may trigger denial: clinical evidence of spinal cord compression; significant vertebral collapse or destruction (e.g., vertebra reduced to less than one-third of original height); healed vertebral compression fracture (VCF); lesions of the sacrum or coccyx (see related New Jersey policy on sacral augmentation); asymptomatic VCFs; and VCFs that are responding appropriately to conservative therapy. These conditions should be excluded by CT or MRI prior to considering percutaneous vertebroplasty or kyphoplasty.

Randomized controlled trials and systematic reviews have not demonstrated consistent clinically important benefit of vertebroplasty versus placebo for routine treatment of acute or subacute osteoporotic VCFs; professional guidance (AAOS, AACE/ACE) does not support vertebroplasty as a first‑line option and emphasizes careful patient selection and prior nonoperative management before augmentation is considered.

The policy explicitly requires CT or MRI to exclude other causes of spinal pain and, in the revision, removed facet arthropathy and other spinal degenerative disease from the list of example alternative pain generators; providers must document imaging and clinical evaluation to demonstrate these exclusions.

Percutaneous vertebral augmentation is usually not appropriate for asymptomatic osteoporotic vertebral compression fractures. Procedures for radiographic-only fractures without correlating signs or symptoms are not supported by the evidence and may be denied.

As part of the policy revisions, examples of alternative causes of spinal pain to be ruled out by CT or MRI were narrowed; specifically, facet arthropathy and other spinal degenerative disease were removed from the illustrative list and should no longer be relied on as required differential examples in documentation guidance.

Use of percutaneous vertebroplasty or kyphoplasty for indications other than the listed covered indications (osteoporotic VCF with symptomatic correlation, certain neoplastic lesions, aggressive hemangioma, osteonecrosis, etc.) is considered unproven and not medically necessary because evidence of efficacy for other indications is insufficient.

Vertebroplasty is inappropriate when the only evidence for a fracture is radiographic (i.e., asymptomatic fractures without correlating clinical signs or symptoms). The Cochrane review and other high-quality trials found no demonstrable benefit of vertebroplasty versus sham in such patients.

The document does not present explicit blanket 'not medically necessary' statements in every section; rather, authors and reviews note areas of low or very low quality evidence for some comparisons and emphasize that many indications remain insufficiently proven pending further high-quality trials.

Professional society guidance cautions against routine vertebroplasty as first‑line treatment: the AAOS (2011, updated 2023) recommends against vertebroplasty for osteoporotic compression fractures and considers kyphoplasty an option in selected patients; AACE/ACE guidance similarly does not recommend vertebral augmentation as first‑line given uncertain benefit and potential harms.

This Medical Policy is informational to help interpret UnitedHealthcare standard benefit plans. Actual coverage decisions are governed by the member's applicable federal, state, or contractual benefit requirements; medical record documentation may be required to assess clinical criteria but does not guarantee coverage.

Procedure, Product and Reference Codes

Referenced 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), 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... each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure).

FDA product codes for bone cement (informational)mixed

NDN, LOD

Product codes referenced for PMMA bone cement (FDA database product codes).

FDA product codes for bone tamps (informational)mixed

HRX, HXG

Product codes referenced for FDA-cleared bone tamps used in balloon kyphoplasty.

References (no explicit codes in this segment)mixed

No codes listed

Policy revision effective date

Policy revision effective date05/01/2026

Policy numberCS330NJ.F

JurisdictionNew Jersey

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests must document that the member meets the medical necessity criteria in this policy and that benefit coverage is governed by the member’s federal, state, or contractual plan terms; this policy is interpretive and does not override plan-specific benefit limits.

Prior authorization required to demonstrate medical necessity
Benefit coverage governed by federal, state, or contractual requirements; in event of conflict, those requirements govern

Prior Authorization

Prior Auth: Document Failed Conservative Management

Prior authorization must include documentation that conservative (noninvasive) therapy has been tried and failed before approval for percutaneous vertebral augmentation. Optimal Medical Therapy (first-line treatments) should be attempted and documented.

Document failure of conservative therapy (e.g., NSAIDs, opioids) or contraindication to these agents
ACR defines failure as pain refractory to oral medications or need for parenteral narcotics and hospital admission

Key Definitions and Terms

Functional or Physical Impairment

DefinitionA Functional or Physical Impairment causes deviation from the normal function of a tissue or organ resulting in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities.

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

Context of useUsed as an eligibility threshold for vertebral augmentation when pain causes functional limitation.

Optimal Medical Therapy

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

ExamplesAnalgesics, bracing, rest, and other noninvasive management per guideline-based care.

Background, Clinical Evidence and Guidance

Percutaneous vertebroplasty (PVP) involves percutaneous injection of polymethylmethacrylate cement into a fractured vertebral body to stabilize the fracture and reduce pain. Balloon kyphoplasty (PKP/BKP) uses an inflatable tamp to create a cavity and potentially restore vertebral height before cement injection; PKP often yields greater radiographic height restoration and lower cement leakage rates in some studies, while both procedures aim to improve pain, function, and quality of life in selected patients.

Evidence summaries by indication (supporting)

Evidence summaries by indication (supporting evidence context):

Osteolytic metastatic disease: Systematic reviews and clinical series indicate PVP/PKP reduce pain and improve function and quality-of-life measures in malignant VCFs; cement leakage common but symptomatic complications rare

Supporting citations: chunks 36-39

Multiple myeloma: Observational studies report rapid, sustained pain relief and functional improvement after vertebral augmentation with low rates of symptomatic complications; evidence is primarily retrospective or case series

Supporting citations: chunks 40-41

Policy Revision History

2026-05-01policy_revisionLatest

Added a related-policy reference to the Medical Policy titled 'Minimally Invasive Spine Surgery Procedures (for New Jersey Only)'; revised 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 language clarifying that benefit coverage is governed by federal, state, or contractual requirements and that medical records may be required to assess clinical criteria; updated definitions for Functional or Physical Impairment, Optimal Medical Therapy, Osteonecrosis, and Vertebral Hemangiomas; and updated Clinical Evidence and References sections.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty and Kyphoplasty (for New Jersey Only)

Policy CodePolicy CS330NJ.F

Change TypeUpdates to imaging differentials, definitions, and documentation expectations

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document failure of optimal conservative therapy, symptomatic fracture within 4 months, and CT/MRI exclusion of other spinal pain generators.

SourceLink

On This Page

acute <3 months; subacute 3-6 months; chronic >6 months

Meta-analyses indicate superior outcomes for acute/subacute symptomatic VCFs

Procedure selection considerations: PVP or PKP may be used; PKP (kyphoplasty) may provide greater vertebral height restoration and lower cement leakage though comparative pain outcomes are similar

Network and comparative reviews show radiographic advantages for PKP but similar pain outcomes

Unstable fractures due to osteonecrosis (Kümmell disease): Multiple comparative studies, prospective cohorts, and network meta-analyses indicate both PVP and PKP relieve pain; PKP often achieves better radiographic correction and lower cement leakage but with greater resource use; BFMC may rank favorably for balancing symptom improvement and leakage in some analyses

Sources: Li, Wang, Zhang, Dai, Chang, Huang (chunks 47,50-55)

Society guidance varies and should be documented in rationale

Conservative management (medical management ± immobilization) is first-line

Prior Authorization

Confirm Refractory Pain and Localization

Prior authorization must confirm that the patient has severe, ongoing pain that localizes to the level of a recent, unhealed vertebral fracture despite optimal management. Clinical correlation between imaging findings and symptoms is required.

Confirm severe ongoing pain after a recent, unhealed fracture despite optimal pain management (NICE)
Confirm pain localizes to the fracture by physical exam and imaging
Documentation should show symptomatic correlation between imaging and clinical pain

Documentation Required

Medical Records and Documentation

Provide complete medical records to support the request. Lack of required documentation or failure to follow coverage requirements may result in denial.

Medical record must include relevant history, physical exam, and results of pertinent diagnostic tests (e.g., CT or MRI)
Documentation must be legible, maintained in the record, and available on request
Incomplete or missing documentation may trigger a denial

Documentation Required

Clinical Correlation and Typical Supporting Documentation

Imaging (CT or MRI) must rule out alternative causes of spinal pain and confirm absence of exclusion conditions. Clinical correlation is required between radiographic findings and patient symptoms.

CT or MRI should exclude foraminal stenosis, herniated disk, or other coexistent spinal pain generators
Documentation should support symptomatic correlation between imaging and clinical pain
Typical supporting items: cross-sectional imaging, severity pain scores, and exam findings

Denial Risk

Conditions That May Trigger Denial

Certain conditions are specified as triggers for denial; prior authorization should document these are absent.

Clinical evidence of spinal cord compression on CT/MRI — denial trigger
Significant vertebral collapse/destruction (e.g., vertebra < one-third original height) — denial trigger
Healed VCFs, asymptomatic VCFs, or VCFs responding to conservative therapy are not appropriate

Denial Risk

Risk From Limited Demonstrated Benefit vs Sham

The evidence base includes randomized trials showing little or no benefit of vertebroplasty versus sham in many studies and reports of serious adverse events. Authorization reviewers should weigh limited demonstrated benefit against potential risks when evaluating requests.

Several RCTs and systematic reviews found no demonstrable clinically important benefit of vertebroplasty vs sham in routine practice
Reported adverse events include cement leakage and additional vertebral fractures
Evidence supports benefit in selected symptomatic, correlated fractures but not for radiographic-only fractures

Note

No Explicit Procedural Authorization Rules in This Policy

No exhaustive procedural prior-authorization code list is specified within this policy. Use the member’s plan requirements and any separate prior authorization tools (eg, InterQual) to identify required codes and submission details.

Applicable procedure codes are provided for reference but do not by themselves determine coverage
UnitedHealthcare may use third‑party tools to assist in administration; follow plan-specific prior authorization pathways

Step Therapy

Noninvasive Alternatives and Step Therapy Context

Before considering vertebral augmentation, noninvasive alternatives such as nerve block or other conservative care modalities should be considered or documented as attempted when clinically appropriate.

Consider nerve block as an alternative or prior step to augmentation (network meta-analysis findings)
Document trials of immobilization, medications, physical therapy, or other conservative measures

RequirementDocumentation of an adequate trial of Optimal Medical Therapy is required before considering vertebral augmentation unless contraindicated or in urgent palliative contexts.

Osteonecrosis

DefinitionOsteonecrosis: disease caused by reduced blood flow to bone (also referred to as avascular necrosis, aseptic necrosis, pseudarthrosis, or Kummel disease) that can lead to bone breakdown and unstable fractures.

Common causes/risk factorsSteroid medications, alcohol use, injury, increased intraosseous pressure; risk factors include radiation, chemotherapy, and organ transplants.

Treatment contextMay cause unstable vertebral fractures considered among covered indications for vertebral augmentation when other criteria are met.

Vertebral Hemangiomas (aggressive)

DefinitionVertebral Hemangiomas are benign vascular tumors of the bony spine; a rare 'aggressive' subset can show extraosseous extension, bone expansion, disturbed blood flow, and occasionally compression fractures and symptoms.

Typical locationMost often occur between T3 and T9 vertebral segments.

RelevanceAggressive hemangiomas are a listed indication for vertebral augmentation when clinical and imaging criteria are satisfied.

HDF / vertebra plana

DefinitionHDF (high-degree fracture) and vertebra plana: HDF indicates vertebral body collapse >50%; vertebra plana indicates >70% collapse.

Clinical relevanceUsed to classify severe OVCFs in studies and may influence consideration of surgical vs conservative management.

Evidence exampleJoyce et al. (2022) categorized fractures and reported favorable pain reduction with percutaneous augmentation in severe fractures without increased complications.

OVCF

DefinitionOVCF: Osteoporotic vertebral compression fracture; vertebral fracture attributed to osteoporosis that may produce acute or subacute pain and functional limitation.

Imaging correlationBone marrow edema or intravertebral cleft on imaging supports symptomatic OVCF eligible for augmentation when correlated clinically.

Appropriate usePercutaneous vertebral augmentation is usually appropriate for symptomatic OVCF with bone marrow edema or intravertebral cleft; asymptomatic OVCF is usually not appropriate.

PVP (percutaneous vertebroplasty)

DefinitionPVP (percutaneous vertebroplasty): percutaneous injection of PMMA cement into a vertebral body to stabilize a fracture and reduce pain.

Clinical evidenceStudied extensively in malignant and benign VCFs; pain and functional improvements reported though some RCTs vs sham show no benefit in certain contexts.

RisksCement leakage is common; symptomatic complications are uncommon but documented in some series and reviews.

PKP / BKP (balloon kyphoplasty)

DefinitionPKP / BKP (balloon kyphoplasty): use of an inflatable balloon to create a cavity and partially restore vertebral height before cement injection.

Comparative effectsAssociated with greater radiographic height restoration and lower cement leakage rates compared with PVP, though clinical pain outcomes are similar in many studies.

Trade-offsPKP often entails longer operation time, higher cost, and greater cement volume than PVP.

Failure of conservative therapy

DefinitionFailure of conservative therapy: pain refractory to oral medications or requiring parenteral narcotics or hospital admission, or when conservative measures are contraindicated.

RequirementDocumentation of inadequate response to conservative/optimal medical therapy is required prior to vertebral augmentation unless contraindicated or in urgent palliative contexts.

Guideline alignmentSociety guidance (SIR/AANS/ACR etc.) recommends augmentation only when nonoperative therapy has not provided adequate relief.

Imaging findings supportive of augmentation

DefinitionImaging findings supportive of augmentation: bone marrow edema or intravertebral cleft on MRI/CT, or other imaging confirming pain localized to the fracture level.

PurposeUsed to confirm symptomatic correlation between imaging and clinical pain for eligibility for augmentation.

EvidenceStudies and reviews report improved outcomes when clinical symptoms correlate with imaging findings (e.g., Pourtaheri, Li; systematic reviews).

Functional or Physical Impairment (updated)

Updated definitionFunctional or Physical Impairment: definition updated in the policy to clarify the nature of limitations and examples of affected activities.

ImplicationUpdated wording is intended to guide documentation supporting medical necessity for vertebral augmentation.

Source noteSee Policy History/Revision Information 05/01/2026 for the update.

Optimal Medical Therapy (updated)

Updated definitionOptimal Medical Therapy: definition updated to emphasize first-line noninvasive treatments that must be tried prior to invasive procedures.

DocumentationPolicy clarifies that documentation of an adequate trial of Optimal Medical Therapy may be required to assess clinical criteria but does not guarantee coverage.

ReferenceUpdated in Policy History/Revision Information (05/01/2026).

Osteonecrosis (updated)

Updated definitionOsteonecrosis: updated definition retained as disease from reduced blood flow (includes Kummel disease) that can cause unstable fractures; policy update noted.

Clinical noteMultiple studies of Kümmell disease report both PVP and PKP relieve pain; PKP often achieves better radiographic correction and lower cement leakage.

DocumentationUpdated definition intended to align policy language with current evidence and may affect eligibility considerations.

Vertebral Hemangiomas (updated)

Updated definitionVertebral Hemangiomas (aggressive): updated to clarify features (extraosseous extension, bone expansion, blood-flow disturbance) and symptomatic potential.

EvidenceCase series and multicenter cohorts report sustained pain relief after PVP for symptomatic aggressive hemangiomas with low symptomatic complication rates.

UsageUpdated wording clarifies when hemangiomas are considered an indication for augmentation (aggressive symptomatic lesions with imaging correlation).

Vertebral hemangioma: Case series demonstrate large reductions in VAS pain scores and low symptomatic complication rates following PVP for aggressive vertebral hemangiomas

Supporting citations: chunk 43