Kyphoplasty and Vertebroplasty Reimbursement Policy
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Defines UHA reimbursement policy, medical necessity criteria, limitations, contraindications, and administrative prior authorization and documentation requirements for kyphoplasty and vertebroplasty for enrolled members and participating providers.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Rules
inv-01: Coverage with Medical Necessity and Administrative Criteria
Covered when ALL of the following clinical and administrative criteria are met:
ALL of the following
- Acute vertebral compression fracture(s) secondary to osteoporosis with severe back pain for at least six weeks
- Failed an optimal and genuine trial of conservative therapy (examples: initial bed rest with progressive activity, physical therapy, and/or analgesics)
- For osteolytic vertebral lesions (metastases or myeloma): severe back pain related to destruction of the vertebral body, and the patient does not have disseminated visceral metastasis or comorbidities predicting a very limited life expectancy
- Reserved use for symptomatic osteolytic spinal metastases with intact bone cortex and without epidural disease, spinal cord compression, or retropulsion of bone fragments
- All patients with osteoporosis receiving vertebral augmentation are being treated medically for osteoporosis to prevent additional fractures
- Evaluation by a spinal or physical medicine specialist has been performed prior to the procedure
- Prior authorization is obtained and submitted via UHA's online portal
ALL of the following
- Imaging and documentation show a high degree of certainty that pain is caused by a non-healing fracture (targeted physical exam and imaging such as x-ray, CT, MRI)
- Include bone scan or MRI if indicated (e.g., fracture age indeterminate)
- Documentation that pain is not caused by a spinal or disc fragment (ancillary study confirmation)
- Vertebral body height is not less than one-third of its original height
inv-02: Limitations and Contraindications
The following limitations, exclusions, and contraindications preclude coverage:
ANY of the following
- No coverage for more than three vertebral bodies in a single operative session
- Not covered if compression fractures are more than one year old
- Kyphoplasty/vertebroplasty is not to be performed as prophylaxis for osteoporosis of the spine or for chronic back pain associated with old, healed compression fractures
- Uncorrected coagulation disorders (contraindication)
- Underlying infection of the involved vertebra (e.g., osteomyelitis) (contraindication)
- Severe cardiopulmonary disease (contraindication)
- Neurological symptoms related to spinal compression (contraindication)
- Allergy to any component required for the procedure (contraindication)
- Consider extent of disease, spinal level involved, and previous treatments before offering kyphoplasty/vertebroplasty; not eligible when the patient's condition makes the procedure unsafe or when there will be limited or no significant improvement in activities of daily living
- Not indicated for patients with mild to moderate pain responding to medical management
Procedure Codes and Coding Limits
| 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 (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). |
| 20225 | Bone biopsy (considered incidental to the kyphoplasty/vertebroplasty procedure and not payable separately). |
Authorization and Documentation Requirements
Prior authorization required — portal contact and required documentation
Prior authorization is required for kyphoplasty/vertebroplasty and must be requested via UHA’s online portal; if you do not have a portal login, contact UHA at 808-532-4000 to establish one. Include documentation demonstrating with targeted physical exam and imaging (x‑ray, CT, MRI) that pain is due to a non‑healing fracture; bone scan or MRI when fracture age is indeterminate; confirmation that pain is not from a spinal/disc fragment; and that the vertebral body height is not less than one‑third of its original height.
- Submit prior authorization requests through UHA’s online portal; call 808‑532‑4000 to establish portal access if needed.
- Include imaging reports (x‑ray, CT, MRI) and bone scan or MRI if indicated to document a non‑healing fracture.
- Provide documentation (ancillary study) confirming pain is not caused by a spinal or disc fragment.
- Document vertebral body height ≥ one‑third of original height.
Key Definitions
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