CurrentUnitedHealthcarePolicy CS330OH.C

Percutaneous Vertebroplasty and Kyphoplasty (for Ohio Only)

Medical policy describing coverage and medical necessity considerations for percutaneous vertebroplasty and kyphoplasty for members in Ohio, including use of InterQual criteria and documentation requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPercutaneous Vertebroplasty and Kyphoplasty (for Ohio Only)

Policy CodePolicy CS330OH.C

Change TypeDocumentation clarification (material)

Effective Date05/01/2026

Next Review Date

Key ActionProvide complete, legible medical record documentation (history, physical exam, and diagnostic test results) and make it available upon request to support medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

Added detailed language clarifying medical records documentation requirements to support medical necessity for requested services.

Ohioapplicable state

InterQualclinical criteria source

22510-22515procedure codes listed

05/01/2026effective date

Coverage and Medical Necessity Criteria

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Medical necessity (InterQual)

Covered when ALL of the following are met per InterQual CP: Procedures, Vertebroplasty or Kyphoplasty

InterQual-based medical necessity: Member meets InterQual CP: Procedures, Vertebroplasty or Kyphoplasty criteria for vertebroplasty or kyphoplastysee InterQual

Use InterQual as the determining clinical criteria

The listing of procedure and diagnosis codes in this policy is provided for reference purposes only and may not be all-inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage is governed by applicable federal, state (Ohio Administrative Code), or contractual requirements and laws, which take precedence and may limit or require coverage beyond this policy.

The inclusion of a code in this policy does not imply a right to reimbursement or guarantee payment of a claim. Coverage and payment require that the requested service meet applicable clinical criteria; services that do not meet the InterQual ® CP: Procedures, Vertebroplasty or Kyphoplasty criteria, or that fail to meet applicable contractual or state requirements, are not covered.

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.
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 Authorization Process

Prior Authorization

InterQual Criteria Required

InterQual criteria are required for medical necessity review of percutaneous vertebroplasty and kyphoplasty. Refer to the InterQual® CP: Procedures, Vertebroplasty or Kyphoplasty when submitting requests; coverage is determined based on those criteria and applicable federal, state (OAC) or contractual benefit requirements.

InterQual® CP: Procedures, Vertebroplasty or Kyphoplasty — required for medical necessity determinations
If InterQual® does not have applicable criteria, UnitedHealthcare may use other approved guidelines per contractual or regulatory requirements

Prior Authorization

Prior authorization is required. Submit the InterQual-guided clinical justification and supporting documentation at the time of authorization request to avoid delays.

Include indication, imaging reports, and prior conservative therapy details in the authorization request
Confirm applicable federal, state (OAC), or contractual requirements that may supersede standard plan provisions

Documentation Required

Required Medical Records Documentation

The patient's medical record must contain documentation that fully supports the medical necessity for the requested service. Provide legible, complete records including relevant history, physical examination, and diagnostic test results.

Relevant medical history and physical exam findings
Pertinent diagnostic test results (eg, imaging reports with description of vertebral compression fracture and timing)
Documentation of symptoms, functional impairment, and response to conservative management

Denial Risk

Documentation-Related Denial Risk

Lack of adequate documentation that supports InterQual criteria or medical necessity may result in denial of the request.

Denials may occur if records do not demonstrate required clinical criteria per InterQual®
Ensure records are available and legible upon request to reduce denial risk

Background

Percutaneous vertebroplasty and kyphoplasty are image-guided procedures performed to treat vertebral compression fractures; kyphoplasty additionally uses cavity creation (e.g., balloon) techniques to attempt restoration of vertebral height. These procedures use devices and materials such as bone tamps and polymethylmethacrylate (PMMA) bone cement, which have FDA classifications and clearances relevant to their use. UnitedHealthcare considers vertebroplasty and kyphoplasty to be proven and medically necessary when all components of the InterQual ® CP: Procedures, Vertebroplasty or Kyphoplasty criteria are met, and uses InterQual as the primary clinical criteria source when determining medical necessity for prior authorization and coverage decisions.

Key Device Definitions

Polymethylmethacrylate (PMMA) bone cement definition

Device class and compositionClass II implantable device composed of methylmethacrylate (PMMA), esters of methacrylic acid, or copolymers containing PMMA and polystyrene; intended to be implanted and used to fix polymer or metallic prosthetic implants to living bone (arthroplasty and other uses)

Regulatory noteA number of PMMA bone cement products have been approved for marketing by the FDA as Class II devices; FDA approval alone is not a basis for coverage

Use in kyphoplastySome PMMA products are cleared for use in kyphoplasty procedures (when used with FDA‑cleared bone tamps)

Reference for product clearancesFDA PMN website (product codes NDN, LOD) for specific marketed bone cement products

Bone tamp definition

Device classificationClass II FDA‑regulated device

Intended functionUsed to create a void in cancellous bone in the spine, including use during balloon kyphoplasty

Regulatory contextFDA has approved bone tamps for creation of a void in cancellous bone and categorizes them as Class II devices

Reference for product clearancesFDA PMN website (product codes HRX, HXG) for specific bone tamp clearances