GoHealthcare MSK Specialty Procedure Library

Kyphoplasty

Percutaneous balloon vertebral augmentation for vertebral compression fracture - prior authorization, medical necessity, coverage, coding, and reimbursement operations.

Developed by Pinky Maniri, Founder and Chief Executive Officer, GoHealthcare Practice Solutions

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Procedure CategoryVertebral Augmentation and Ablation

Operational FocusMedical necessity, payer policy, prior authorization, coding, reimbursement, and denial prevention

Coding Reference Year2026 - verify current codes and payer policy before use

GoHealthcare Operational Results

98%Company-reported prior authorization approval rate

50 StatesNational prior authorization and utilization-management support

MSK FocusPain, spine, orthopedics, PM&R, and ambulatory surgery center operations

Company-reported performance. Results vary by client, payer, specialty, documentation quality, benefit design, and case mix. No authorization or payment outcome is guaranteed.

Operational use: This page is designed for physicians, APPs, prior authorization teams, utilization-management nurses, coding and revenue-cycle professionals, ASCs, hospitals, and healthcare executives. It is not a procedural technique manual. Always verify the controlling policy and code set for the individual patient and date of service.

Page Contents

Use the links below to move directly to the clinical, payer, documentation, coding, reimbursement, and denial-management sections.

Clinical and Coverage Foundation

1. Overview
2. Evidence at a Glance
3. Procedure Overview
4. Relevant Anatomy
5. Clinical Indications
6. Patient Selection
7. Contraindications and Precautions
8. Medical Necessity
9. Conservative Treatment Requirements
10. Diagnostic Prerequisites and Treatment Sequencing
11. CMS National Coverage Determinations and National Guidance
12. Medicare LCDs, Billing and Coding Articles, and MAC Guidance

Payer, Documentation, Coding and Revenue

13. Commercial Payer Policies and Guidelines
14. Delegated Utilization-Management Guidelines
15. Evidence-Based Clinical and Specialty-Society Guidelines
16. Policy and Guideline Comparison Matrix
17. Prior Authorization Requirements
18. Documentation Requirements
19. Documentation Pearls
20. CPT and HCPCS Coding
21. ICD-10-CM Crosswalk
22. Billing Integrity: Modifiers, Units, NCCI, MUE, and Place of Service
23. Reimbursement Considerations
24. Denial Prevention

Denials, Operations and Resources

25. Common Denial Reasons
26. Appeals, Reconsideration, and Peer-to-Peer
27. Operational Workflow
28. Payer Perspective
29. Clinical Pearls
30. GoHealthcare Perspective
31. GoHealthcare Insights
32. Frequently Asked Questions
33. GoHealthcare Case Study
34. Related Procedures and Resources
35. References and Reading Recommendations
36. Standard Disclaimer

01

Foundation

Overview

Kyphoplasty is a percutaneous vertebral augmentation procedure defined by mechanical cavity creation before cement placement. Operational success depends on proving an active vertebral compression fracture, matching the tender, imaged, and requested level, documenting fracture age and functional impairment, selecting a policy-recognized technique, and preserving one-primary-plus-add-on coding integrity.

GoHealthcare operational objective

Align the clinical record, payer policy, authorization, scheduled service, coding, and claim before the procedure occurs. This reduces avoidable delays, peer-to-peer escalation, denials, and post-payment exposure.

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02

Foundation

Evidence at a Glance

Kyphoplasty (percutaneous balloon vertebral augmentation) is an image-guided, minimally invasive procedure in which a cavity is created within a fractured vertebral body using an inflatable bone tamp or comparable mechanical device, after which bone cement (polymethylmethacrylate, PMMA) is injected to stabilize the fracture and reduce pain. It is distinguished from vertebroplasty by the deliberate cavity-creation / height-restoration step. The table below summarizes the operational coverage landscape.

Domain	Summary Position (verify per payer / date of service)
Medicare NCD	No National Coverage Determination specific to vertebral augmentation. Coverage is governed by MAC Local Coverage Determinations (LCD) and companion Local Coverage Articles (LCA).
Medicare LCD	Multiple MAC LCDs for Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF): e.g., L33569, L34228, L34976, L35130, L38213, L38737, with billing/coding articles A57630, A57752, A57872. Criteria are broadly aligned across MACs.
Commercial coverage	Covered as medically necessary for painful acute/subacute osteoporotic VCF and for malignant/osteolytic VCF meeting criteria (Aetna, Cigna/eviCore CMM-607, UnitedHealthcare, Humana, BCBS plans). Radiofrequency kyphoplasty is considered experimental by several payers.
Evidence level	Supported for select patients: FREE (Lancet 2009), VAPOUR (Lancet 2016), EVOLVE (2018), CAFE for cancer VCF (Lancet Oncol 2011), SAKOS for mechanical augmentation (Spine J 2019). Two 2009 sham-controlled RCTs (Buchbinder; Kallmes) were negative and remain the basis for payer scrutiny; Medicare-registry analyses suggest a mortality benefit.
Image guidance	Fluoroscopy or CT guidance is inherent to the procedure and is bundled into the CPT descriptors (not separately reportable).
Prior authorization	Commonly required by commercial and Medicare Advantage plans; frequently delegated to eviCore, Carelon, or a comparable UM vendor. Traditional Medicare does not require prior authorization for the professional service but enforces LCD medical-necessity criteria on the claim.
Conservative therapy	Documented failure of, contraindication to, or intolerance of non-surgical management is expected; the acute/subacute VCF pathway generally shortens the required conservative interval versus chronic degenerative pain procedures.
Key imaging	Advanced imaging demonstrating an active/edematous fracture (MRI STIR bone-marrow edema, or bone scan / SPECT-CT uptake) that correlates with the clinical level is the single most important approval element.
Coding snapshot	22513 (thoracic), 22514 (lumbar), +22515 (each additional thoracic or lumbar level). No Category I/III code exists for cervical augmentation (use 22899). Bone biopsy and imaging guidance are bundled.
Typical approval driver	A tight clinical-radiographic-anatomic correlation: point tenderness at the fractured level + acute/subacute edematous fracture on advanced imaging + disabling pain refractory to (or inappropriate for) conservative care.

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03

Clinical Foundation

Procedure Overview

Vertebral compression fractures (VCFs) are the most common osteoporotic fracture and a frequent consequence of metastatic disease and multiple myeloma. Untreated, painful VCFs drive immobility, progressive kyphotic deformity, reduced pulmonary function, opioid exposure, and, in older adults, measurable increases in morbidity and mortality. Kyphoplasty is a percutaneous, image-guided stabilization procedure intended to relieve fracture-related pain, arrest progressive collapse, and in many cases partially restore vertebral body height and correct segmental angular deformity. Mechanistically, one or two cannulas are advanced into the vertebral body (typically transpedicular or extrapedicular). An inflatable bone tamp or comparable mechanical device creates a cavity and attempts to elevate the depressed endplates; the balloon is then removed and the cavity is filled with bone cement under low pressure. The engineered

cavity is the defining feature that separates kyphoplasty from vertebroplasty, in which cement is injected directly into the cancellous bone without cavity creation. From an operational standpoint, this distinction maps directly to two separate CPT code families and to differing device utilization, facility costs, and payer language. This guide is written for the teams that must consistently obtain authorization and clean reimbursement for the procedure: physicians and advanced practice providers who document, prior authorization and utilization management staff who submit and defend requests, revenue cycle and coding professionals, and ASC / hospital outpatient department leaders. It intentionally emphasizes the documentation, coverage, and coding requirements that surround the procedure rather than operative technique.

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04

Clinical Foundation

Relevant Anatomy

Only the anatomy relevant to patient selection, medical necessity, and documentation is summarized here. Each vertebra consists of an anterior weight-bearing vertebral body and a posterior arch (pedicles, laminae, transverse and spinous processes). Compression fractures involve the vertebral body and are commonly described by morphology (wedge, biconcave, or crush) and by location within the anterior, middle, or posterior column.

• Thoracolumbar junction (T11-L2) is the most common site of osteoporotic VCF because of the biomechanical transition from the rigid thoracic cage to the mobile lumbar spine.
• Vertebral endplates and cancellous core are the target of cavity creation and cement interdigitation; the integrity of the posterior vertebral body wall is a key safety and selection consideration because posterior wall disruption raises the risk of cement extravasation into the spinal canal.
• Basivertebral neurovascular foramen on the posterior vertebral body is relevant only as an anatomic landmark here; it is the therapeutic target of a separate procedure (basivertebral nerve ablation) addressed in a companion guide.
• Spinal cord, conus medullaris, and exiting nerve roots lie immediately posterior to the vertebral body; their proximity underlies the imaging and documentation emphasis on posterior wall integrity and canal compromise.

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05

Clinical Foundation

Clinical Indications

Kyphoplasty is generally indicated for a painful vertebral body compression fracture that correlates with clinical findings and advanced imaging, when the fracture is judged to be the dominant pain generator. Recognized indication categories include:

• Osteoporotic VCF that is acute or subacute (symptom onset generally within approximately 6 weeks, and often up to 3 months) with an active/edematous fracture on advanced imaging and moderate-to-severe, disabling axial pain.
• Malignant / osteolytic VCF from primary bone malignancy, multiple myeloma, or metastatic disease, causing painful vertebral collapse refractory to conservative care (a well-recognized palliative indication).
• VCF refractory to, or inappropriate for, non-surgical management where prolonged immobilization, bracing, or systemic analgesia would carry unacceptable risk (for example, opioid intolerance or the risks of prolonged bed rest in an older adult).
• Progressive collapse or kyphotic deformity on serial imaging in a symptomatic patient.

GoHealthcare Clinical Insight

The strongest indication narrative ties three elements together in one sentence: the level of point tenderness, the acute/subacute edematous fracture at that same level on MRI or bone scan, and the functional consequences of the pain. Requests that describe pain and imaging separately, without asserting concordance, are the ones most often stopped for clinical review.

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06

Clinical Foundation

Patient Selection

Appropriate selection is the pivot on which both clinical outcome and payer approval turn. Documentation should demonstrate that the fractured level is the pain generator and that the fracture is physiologically active.

• Focal, reproducible midline or paraspinal tenderness/percussion pain at the radiographically fractured level.
• Moderate-to-severe pain with functional impairment (use a validated pain score and describe specific activity limitation); pain refractory to or inappropriate for conservative management.
• Advanced imaging confirmation of an active fracture (bone-marrow edema on MRI STIR/T2, or increased uptake on bone scan / SPECT-CT) at the symptomatic level.
• Absence of a more compelling alternative pain source (for example, radicular pain from stenosis or disc herniation) that would not be addressed by augmentation.
• Realistic goals and the ability to tolerate brief prone positioning and the procedure itself.

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07

Clinical Foundation

Contraindications and Precautions

Contraindications are both clinical and, for coverage purposes, documentation triggers because they map to common denial rationales.

• Absolute / near-absolute: active local or systemic infection (osteomyelitis, discitis, bacteremia); uncorrectable coagulopathy; true allergy to cement or opacification agent; asymptomatic or radiographically healed fracture (no active pain generator).
• Relative: retropulsed fragment or posterior vertebral body wall disruption with canal compromise; severe vertebra plana limiting instrument access; radiculopathy or myelopathy as the dominant symptom; fracture morphology unlikely to respond; substantial coagulopathy that can be corrected.
• Coverage-relevant framing: chronic, healed, or non-edematous fractures without an active pain generator are the most common medical-necessity denial and should be affirmatively addressed in the record.

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08

Coverage and Medical Necessity

Medical Necessity

Medical necessity for kyphoplasty is established by demonstrating a painful, active vertebral body fracture that is the dominant pain generator and that is refractory to, or inappropriate for, non-surgical care. The reviewer is evaluating concordance among symptoms, examination, and advanced imaging, not merely the presence of a fracture on a film.

Elements that consistently establish medical necessity

• Documented fracture etiology (osteoporotic, malignant/osteolytic, or traumatic) and fracture age (acute/subacute vs chronic).
• Validated pain score and specific functional impairment attributable to the fracture.
• Advanced imaging (MRI edema or bone-scan/SPECT-CT uptake) correlating with the symptomatic level.
• Point tenderness at the corresponding level on examination.
• Conservative care attempted, contraindicated, or failed, with the urgency rationale for early intervention where applicable.
• For malignant VCF, the underlying neoplastic diagnosis and its coding linkage.
• An explicit medical-necessity statement connecting these findings to the requested level(s).

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09

Coverage and Medical Necessity

Conservative Treatment Requirements

Unlike elective procedures for chronic degenerative pain, vertebral augmentation for acute VCF is explicitly time-sensitive: the evidence and most coverage policies favor early intervention in appropriately selected patients rather than a mandatory multi-month conservative trial. The record should nonetheless document that non-surgical management was attempted, is contraindicated, or has failed, and should explain the clinical urgency.

• Analgesic regimen tried and the response or intolerance (including opioid-sparing rationale where relevant).
• Activity modification, bracing/orthosis, and/or physical therapy as tolerated.
• Duration of symptoms relative to imaging (acute versus subacute) and any progression on serial films.
• For older adults, explicit documentation of the risks of prolonged immobilization or escalating opioids that make early augmentation the safer pathway.

GoHealthcare Prior Authorization Insight

Payers increasingly distinguish acute/subacute augmentation (short conservative interval, strong urgency narrative) from chronic-fracture requests (heightened scrutiny). State the symptom duration and the imaging-confirmed fracture age in the same paragraph so the reviewer does not have to reconstruct the timeline.

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10

Coverage and Medical Necessity

Diagnostic Prerequisites and Treatment Sequencing

Imaging is the decisive medical-necessity element for vertebral augmentation. The record should establish (1) the presence and level of the fracture, (2) that the fracture is physiologically active, and (3) that the posterior wall and

canal status support safe augmentation.

• Plain radiographs (standing when feasible): identify compression, quantify height loss, and assess alignment; comparison with prior films documents progression.
• MRI (preferred): STIR / T2 bone-marrow edema is the hallmark of an acute/subacute fracture and the finding payers most want to see; MRI also screens for infection, malignancy, and canal compromise.
• Bone scan / SPECT-CT: an accepted alternative to demonstrate an active fracture when MRI is contraindicated (for example, incompatible implanted device).
• CT: best defines posterior wall integrity, retropulsion, and cortical detail for procedural safety and selection.
• Timeliness: several LCDs expect advanced imaging within roughly 30 days of the planned procedure to confirm the fracture remains active.

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11

Medicare Policy

CMS National Coverage Determinations and National Guidance

CMS has no National Coverage Determination specific to percutaneous vertebral augmentation. Medicare coverage is administered through MAC Local Coverage Determinations and companion Billing and Coding Articles. The absence of an NCD does not establish automatic coverage; the applicable jurisdictional policy and reasonable-and-necessary standard remain controlling.

National coverage rule

No procedure-specific NCD does not mean automatic coverage or automatic noncoverage. The applicable MAC policy, benefit category, documentation, and reasonable-and-necessary standard remain controlling.

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12

Medicare Policy

Medicare LCDs, Billing and Coding Articles, and MAC Guidance

There is no National Coverage Determination that governs vertebral augmentation; coverage is administered through Medicare Administrative Contractor (MAC) Local Coverage Determinations and their companion Billing and Coding Articles. Although the LCDs are issued by different MACs, their medical-necessity criteria are closely aligned. The following synthesis reflects the common positions across the PVA-for-VCF LCDs (for example, L33569, L34228, L34976, L35130, L38213, and L38737) and their articles (A57630, A57752, A57872). Do not reproduce policy language verbatim; always read the LCD that applies to the patient's MAC jurisdiction and date of service.

Common Medicare coverage criteria (synthesized)

• Acute (generally under 6 weeks) or subacute (roughly 6-12 weeks) osteoporotic VCF, typically T1-L5, based on symptom onset and confirmed by recent advanced imaging showing an active fracture (bone-marrow edema on MRI, or bone scan / SPECT-CT uptake).
• Moderate-to-severe pain and functional impairment that correlate with the fracture level and are refractory to, or inappropriate for, conservative management.
• Coverage also recognized for painful malignant/osteolytic compression fractures refractory to conservative care as a palliative indication.
• Point tenderness and clinical-radiographic concordance at the treated level.

Medicare documentation and billing notes

• Bone biopsy (20225, 20250, 20251) at the same level is integral and is not separately payable.
• Imaging guidance and, where applicable, moderate sedation are bundled into the augmentation codes.
• The assistant-at-surgery Medicare payment indicator for these codes is 1; an assistant at surgery is not payable.
• Correct ICD-10-CM selection supports but does not guarantee coverage; the service must independently meet the reasonable-and-necessary standard in the applicable LCD.

GoHealthcare Clinical Insight - Medicare

Traditional Medicare does not prior-authorize the professional service, which can create a false sense of security. The medical-necessity test still applies at claim adjudication and on audit. The safest posture is to build the record as though it will be reviewed: imaging report language documenting edema/uptake at the treated level, a dated symptom-onset note, and a level-specific medical-necessity statement in the operative documentation.

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13

Payer Policy

Commercial Payer Policies and Guidelines

Commercial coverage is plan-, product-, jurisdiction-, and effective-date-specific. The table below includes representative commercial payer positions from the source guide; verify the live policy and member benefits before submission.

Payer / Vendor	PA Pathway	Representative Position (verify current policy)
UnitedHealthcare	PA required (commercial); MA per plan	Maintains a 'Percutaneous Vertebroplasty and Kyphoplasty' medical policy (updated effective March 1, 2026) covering osteoporotic VCF and osteolytic lesions refractory to medical therapy under defined criteria.
Aetna	PA / precertification per plan	CPB 0016 (Back Pain: Invasive Procedures) considers PPV, kyphoplasty, and the SpineJack system medically necessary for debilitating osteoporotic acute/subacute fracture, primary bone malignancy, or osteolytic metastasis, with pain localized to the pathology level and other causes excluded by CT/MRI.
Humana	PA per plan / MA	Covers augmentation for qualifying painful VCF; MA plans apply the applicable LCD criteria and internal coverage policy.
Blue Cross Blue Shield plans	PA per plan; some vendor-managed	Plan-specific medical policies (e.g., BCBS FL, Blue Cross NC, Blue Shield CA MP 6.01.38) cover balloon kyphoplasty for qualifying VCF; radiofrequency kyphoplasty is generally considered experimental/investigational.

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14

Utilization Management

Delegated Utilization-Management Guidelines

Delegated utilization-management entities apply clinical review criteria on behalf of specific payer products. Delegation must be verified for the individual member; the UM vendor does not independently establish the member benefit or guarantee claim payment.

Payer / Vendor	PA Pathway	Representative Position (verify current policy)
eviCore (Cigna and delegated plans)	PA via eviCore MSK / Spine Surgery	CMM-607 'Primary Vertebral Augmentation (Percutaneous Vertebroplasty-Kyphoplasty) and Sacroplasty.' Coverage for painful osteoporotic and malignant VCF with imaging correlation; policy versions are dated (a version effective 08/04/2026 has been published) - confirm the edition in force.
Carelon Medical Benefits Management	PA via Carelon (per plan)	Administers musculoskeletal / spine surgery programs for multiple plans; augmentation is reviewed against acute/subacute fracture, imaging, and conservative-care criteria similar to eviCore and the MAC LCDs.
Cigna	PA via eviCore	Uses eviCore CMM-607 criteria for vertebral augmentation and sacroplasty; spine-related services are eviCore-delegated for applicable plans.

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15

Clinical Evidence

Evidence-Based Clinical and Specialty-Society Guidelines

The evidence is supportive for carefully selected patients but remains scrutinized. The source guide identifies randomized and prospective evidence supporting balloon kyphoplasty and vertebral augmentation in selected acute, subacute, and malignant fractures, while also acknowledging negative sham-controlled vertebroplasty trials that continue to influence payer review. Clinical evidence should be used to support selection and peer-to-peer preparation, not represented as a universal coverage rule.

Clinical evidence is not payer policy

Use trials, systematic reviews, and specialty-society statements to support patient selection and peer-to-peer discussion. Coverage still depends on the applicable benefit plan, payer policy, MAC jurisdiction, and effective date.

Key clinical evidence and society resources

• Wardlaw D, et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE). Lancet. 2009;373(9668):1016-1024.
• Clark W, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR). Lancet. 2016;388:1408-1416.
• Berenson J, et al. Balloon kyphoplasty versus non-surgical fracture management for cancer-related vertebral fractures (CAFE). Lancet Oncol. 2011;12(3):225-235.
• Buchbinder R, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361(6):557-568.
• Kallmes DF, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361(6):569-579.
• Noriega D, et al. Titanium implantable vertebral augmentation device versus balloon kyphoplasty (SAKOS). The Spine Journal. 2019;19(11):1782-1795.
• North American Spine Society (NASS). Coverage Policy Recommendations. https://www.spine.org

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16

Policy Comparison

Policy and Guideline Comparison Matrix

This comparison separates the controlling Medicare pathway from commercial payer and delegated utilization-management review. Policy editions, products, jurisdictions, and delegation arrangements change; verify the live source for the member and date of service.

Medicare comparison point

CMS has no National Coverage Determination specific to percutaneous vertebral augmentation. Medicare coverage is administered through MAC Local Coverage Determinations and companion Billing and Coding Articles. The absence of an NCD does not establish automatic coverage; the applicable jurisdictional policy and reasonable-and-necessary standard remain controlling.

Payer / Vendor	PA Pathway	Representative Position (verify current policy)
eviCore (Cigna and delegated plans)	PA via eviCore MSK / Spine Surgery	CMM-607 'Primary Vertebral Augmentation (Percutaneous Vertebroplasty-Kyphoplasty) and Sacroplasty.' Coverage for painful osteoporotic and malignant VCF with imaging correlation; policy versions are dated (a version effective 08/04/2026 has been published) - confirm the edition in force.
Carelon Medical Benefits Management	PA via Carelon (per plan)	Administers musculoskeletal / spine surgery programs for multiple plans; augmentation is reviewed against acute/subacute fracture, imaging, and conservative-care criteria similar to eviCore and the MAC LCDs.
UnitedHealthcare	PA required (commercial); MA per plan	Maintains a 'Percutaneous Vertebroplasty and Kyphoplasty' medical policy (updated effective March 1, 2026) covering osteoporotic VCF and osteolytic lesions refractory to medical therapy under defined criteria.
Aetna	PA / precertification per plan	CPB 0016 (Back Pain: Invasive Procedures) considers PPV, kyphoplasty, and the SpineJack system medically necessary for debilitating osteoporotic acute/subacute fracture, primary bone malignancy, or osteolytic metastasis, with pain localized to the pathology level and other causes excluded by CT/MRI.
Cigna	PA via eviCore	Uses eviCore CMM-607 criteria for vertebral augmentation and sacroplasty; spine-related services are eviCore-delegated for applicable plans.
Humana	PA per plan / MA	Covers augmentation for qualifying painful VCF; MA plans apply the applicable LCD criteria and internal coverage policy.
Blue Cross Blue Shield plans	PA per plan; some vendor-managed	Plan-specific medical policies (e.g., BCBS FL, Blue Cross NC, Blue Shield CA MP 6.01.38) cover balloon kyphoplasty for qualifying VCF; radiofrequency kyphoplasty is generally considered experimental/investigational.

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17

Prior Authorization

Prior Authorization Requirements

A complete kyphoplasty request should include the symptom-onset date, advanced imaging report showing an active fracture, examination findings at the same level, pain and functional-impact documentation, conservative-care failure or urgency rationale, requested CPT codes and levels, planned device or technique, and the applicable policy edition. The final authorization must match the scheduled level, setting, and validity period.

Authorization-to-claim integrity

Confirm that the approved code, level, units, site of service, servicing provider, authorization period, and planned procedure match the service that will be performed and billed.

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18

Documentation

Documentation Requirements

Use this as a pre-submission and pre-claim gate. Every item present converts most augmentation requests into first-pass approvals.

• Validated pain score and specific functional impairment attributable to the fracture
• Symptom-onset date establishing acute or subacute fracture age
• Fracture etiology stated (osteoporotic / malignant-osteolytic / traumatic)
• Advanced imaging report noting bone-marrow edema (MRI) or uptake (bone scan / SPECT-CT) at the treated level
• Posterior wall integrity / canal status addressed for safety and selection
• Point tenderness documented at the corresponding level on examination
• Conservative care attempted, contraindicated, or inappropriate, with urgency rationale
• Competing pain sources (radicular / stenotic) affirmatively addressed
• For malignant VCF: underlying neoplastic diagnosis documented and coded
• Level-specific medical-necessity statement linking findings to each requested level
• Planned device/technique reconciled against the specific payer policy edition
• Authorization number, approved levels, setting (ASC/HOPD), and validity window on file

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19

Documentation

Documentation Pearls

Drawn from GoHealthcare's experience supporting musculoskeletal specialty practices, the following operational patterns most reliably improve approval rates and reduce rework for vertebral augmentation.

• Write the imaging correlation into the note, not just the imaging order. Reviewers approve on the narrative in the clinical record; a radiology report buried in the chart without a corresponding clinician statement is the most common reason a strong case still pends.
• Time-stamp the fracture. A single sentence pairing symptom-onset date with the imaging-activity finding resolves the acute-versus-chronic question that drives most denials.
• Standardize the level language. Ensure the tender level, the imaged level, and the requested level are stated identically across the note, the imaging report, and the authorization request.
• Pre-clear the device. Reconcile the planned system against the policy edition at scheduling, particularly for radiofrequency or implant-based augmentation.

Pearls

• One sentence linking symptom-onset date to imaging-confirmed edema resolves most acute-versus-chronic denials.
• Harmonized level language across note, imaging, and request eliminates discordance flags.
• A three-sentence peer-to-peer script (fracture age, imaging activity, level concordance) reverses most pends.

Pitfalls

• Multi-level coding errors (double primary codes) that trigger CCI-related denials.
• Wrong ICD-10 encounter character contradicting the 'acute fracture' narrative.
• Device/technique mismatches that convert a strong clinical case into a technique denial.

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20

Coding

CPT and HCPCS Coding

This overview is operational, not a reimbursement-methodology treatment. Fee schedules, NCCI edit tables, MUE values, and payment rates belong to the GoHealthcare Revenue Cycle Knowledge Center. The coding fundamentals below drive clean claims for kyphoplasty.

• Report exactly one primary code per session (22513 thoracic or 22514 lumbar) plus one unit of add-on +22515 for each additional thoracic or lumbar body treated - even when the additional level is in the other region and even when levels are non-contiguous.
• Do not report 22513 and 22514 together; the first level treated selects the single primary code by its region, and all further levels are +22515.
• Imaging guidance and, when performed, cavity creation, fracture reduction, and bone biopsy are included in the code; do not unbundle.
• Place of service is typically the ASC (24) or hospital outpatient (19/22); inpatient (21) applies when clinically warranted. Device and cement costs are packaged into the facility payment.
• Cervical augmentation has no Category I or III code; report 22899 (unlisted) with documentation.

CPT(R)	Descriptor (abbreviated)	Coding Notes
22513	Percutaneous vertebral augmentation, incl. cavity creation using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, incl. all imaging guidance; thoracic	Primary code when the first level treated is thoracic. One primary per session.
22514	Same as above; lumbar	Primary code when the first level treated is lumbar. Do not report with 22513 for a second level - use +22515.
+22515	Same as above; each additional thoracic or lumbar vertebral body (list separately in addition to primary)	Add-on for every additional level, thoracic or lumbar, contiguous or not. Do not append modifier 51 or 59.
22899	Unlisted procedure, spine	Used to report cervical augmentation (no Category I/III code exists); submit with supporting documentation.

Bundling reminders. Do not separately report bone biopsy (20225/20250/20251) at the same level, imaging guidance, or moderate sedation. Do not report 22513-22515 with 22310, 22315, 22325, or 22327 at the same level.

No distinct HCPCS Level II code is required to report the physician (professional) service for kyphoplasty; the CPT codes above capture the work. Device-related HCPCS considerations arise in the facility setting:

• Bone cement, inflatable bone tamps, cannulae, and mechanical augmentation implants are generally packaged into the facility payment (OPPS APC for HOPD; the ASC payment for ASC) rather than separately billed.
• In specific outpatient settings, device pass-through or facility C-codes may apply under OPPS; confirm current status in the applicable OPPS addenda and the facility's chargemaster.
• Because packaging rules and any pass-through status change annually, verify device coding against the current CMS OPPS/ASC files rather than carrying forward prior-year assumptions.

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21

Diagnosis Coding

ICD-10-CM Crosswalk

The codes below commonly support medical necessity for kyphoplasty. Selection depends on etiology (osteoporotic, malignant, traumatic), encounter type (initial / subsequent / sequela), and vertebral region. Always code to the highest documented specificity and observe Excludes1 relationships. Verify against the current MAC article's covered-diagnosis list.

ICD-10-CM	Description	Notes
M80.08XA	Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter	Most common osteoporotic VCF code. Use ...D (subsequent) / ...S (sequela) as appropriate. Excludes1: collapsed vertebra NOS (M48.5-) and pathological fracture NOS (M84.4-).
M80.88XA	Other osteoporosis with current pathological fracture, vertebra(e), initial encounter	Osteoporosis from other causes (e.g., drug-induced, secondary).
M84.48XA	Pathological fracture, other site, initial encounter	Used for pathological vertebral fracture not otherwise classified; billable at this level.
M84.58XA	Pathological fracture in neoplastic disease, other specified site, initial encounter	Requires an additional code for the underlying neoplasm (see below).
M48.54XA / M48.55XA / M48.56XA / M48.57XA	Collapsed vertebra, NEC - thoracic / thoracolumbar / lumbar / lumbosacral region, initial encounter	Region-specific 6th character required; 7th character A/D/S. Residual category - use only when the collapse is not attributable to osteoporosis (M80.-), neoplasm (M84.58-), or trauma (S22.- / S32.-), each of which is an Excludes1. Do not default to M48.5- when M80 or M84.58 is documented.
S22.0- / S32.0-	Fracture of thoracic vertebra / lumbar vertebra (traumatic)	Traumatic fractures; require full site specificity and 7th character. Most PVA LCDs address osteoporotic / malignant fractures rather than acute high-energy trauma.
C41.2	Malignant neoplasm of vertebral column	Underlying-neoplasm code paired with M84.58XA for malignant VCF.
C79.51 / C79.52	Secondary malignant neoplasm of bone / bone marrow	Metastatic disease to vertebra; pair with the pathological-fracture code.
C90.00	Multiple myeloma, not having achieved remission	Common cause of osteolytic VCF; pair with the pathological-fracture code.

GoHealthcare Coding Insight

The two highest-frequency ICD-10 errors on augmentation claims are (1) using a non-active or wrong-encounter 7th character that contradicts an 'acute fracture' narrative, and (2) coding a malignant VCF with only the fracture code while omitting the required underlying-neoplasm code. Both are avoidable with a two-line coder check.

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Billing Integrity

Billing Integrity: Modifiers, Units, NCCI, MUE, and Place of Service

Modifier	Use	Notes
50 (bilateral)	Not appropriate	The CPT descriptors already specify 'unilateral or bilateral cannulation'; do not append 50. LT/RT are not required.
51 (multiple procedures)	Do not append to +22515	Add-on codes are exempt from multiple-procedure reduction and from modifier 51.
59 / X{EPSU}	Rarely applicable	Do not use to bypass the correct primary-plus-add-on structure; use only for a genuinely distinct service that is separately reportable.
22 (increased procedural services)	Situational	Only with documentation substantiating significantly increased work; expect manual review.
26 / TC	Setting-dependent	Professional/technical split considerations in facility settings; imaging guidance is bundled, so use is limited.
RT / LT	Not required	Laterality modifiers are unnecessary given the unilateral/bilateral descriptor.

This overview is operational, not a reimbursement-methodology treatment. Fee schedules, NCCI edit tables, MUE values, and payment rates belong to the GoHealthcare Revenue Cycle Knowledge Center. The coding fundamentals below drive clean claims for kyphoplasty.

• Report exactly one primary code per session (22513 thoracic or 22514 lumbar) plus one unit of add-on +22515 for each additional thoracic or lumbar body treated - even when the additional level is in the other region and even when levels are non-contiguous.
• Do not report 22513 and 22514 together; the first level treated selects the single primary code by its region, and all further levels are +22515.
• Imaging guidance and, when performed, cavity creation, fracture reduction, and bone biopsy are included in the code; do not unbundle.
• Place of service is typically the ASC (24) or hospital outpatient (19/22); inpatient (21) applies when clinically warranted. Device and cement costs are packaged into the facility payment.
• Cervical augmentation has no Category I or III code; report 22899 (unlisted) with documentation.

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Reimbursement

Reimbursement Considerations

Report one primary kyphoplasty code per session - 22513 when the first treated level is thoracic or 22514 when it is lumbar - plus +22515 for each additional thoracic or lumbar vertebral body. Imaging guidance, cavity creation, and bone biopsy at the treated level are included. Device, balloon, cement, and related supply costs are generally packaged into facility payment. Confirm current OPPS or ASC status, payer contract terms, MUEs, NCCI edits, authorization-to-claim matching, and patient liability before billing.

Authorization does not guarantee payment

Payment remains subject to eligibility, benefit design, coding accuracy, medical necessity, contract terms, claim edits, site of service, and the payer policy in effect on the date of service.

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Denial Management

Denial Prevention

• Adopt a structured augmentation intake template that requires symptom-onset date, imaging-activity statement, and level correlation before a request can be submitted.
• Attach the advanced-imaging report (not just the order) to every request.
• Standardize a level-specific medical-necessity statement macro that names the treated level(s).
• Reconcile device/technique against the effective policy edition at scheduling.
• Run a coder QA pass for one-primary-plus-add-on structure, ICD-10 encounter specificity, and neoplasm dual-coding.
• Retain the full authorization trail (number, levels, setting, validity window) to support post-payment audit defense.

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Denial Management

Common Denial Reasons

Denial Rationale	Root Cause	Prevention
Fracture not demonstrated to be acute/active	No MRI edema or bone-scan uptake documented at the treated level	Attach advanced imaging report explicitly noting edema/uptake at the symptomatic level; state symptom onset date.
Chronic / healed fracture	Symptom duration or imaging suggests a non-active fracture	Document current pain, recent imaging activity, and any progression; address healed-fracture concern head-on.
Conservative care not documented	Record silent on non-surgical management or its inappropriateness	Summarize analgesics, bracing, activity modification, or the specific contraindication/urgency rationale.
Level discordance	Requested level does not match the tender / imaged level	Reconcile examination, imaging, and requested levels before submission.
Alternative pain source	Radicular or stenotic pain appears dominant	Affirmatively rule in the fracture as the pain generator and address competing sources.
Experimental technique flag	Radiofrequency kyphoplasty or an off-policy device	Confirm the planned device/technique is covered under the specific policy edition.
Wrong policy edition / expired auth	Submitted against a superseded policy or outside the validity window	Verify the effective-dated policy and schedule within the authorization window.

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Appeals

Appeals, Reconsideration, and Peer-to-Peer

Most augmentation denials are correlation or timing denials, not true non-coverage. Effective appeals restore the missing linkage rather than re-arguing the merits of the procedure.

• Lead with a one-paragraph correlation statement: tender level = imaged active-fracture level = requested level.

• Quote the operative imaging finding (edema/uptake) and the symptom-onset date to establish an acute/subacute fracture.
• Attach the specific LCD or policy criterion the case satisfies and map the record to each element.
• For malignant VCF, include the oncologic diagnosis and the palliative rationale.
• Prepare the treating physician for a focused peer-to-peer on fracture age, imaging activity, and level concordance; a crisp verbal summary of these three points frequently reverses the pend.
• Escalate procedurally (expedited appeal, independent review) where the fracture is acute and delay risks clinical deterioration.

GoHealthcare Best Practices

The best appeal is the one you never file. A pre-submission checklist that forces the three correlation elements and the imaging-activity statement into every request eliminates the majority of augmentation pends before they occur.

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Operations

Operational Workflow

The following workflow describes the end-to-end path from evaluation through scheduling and post-service documentation. Traditional Medicare omits the pre-service authorization step but requires the same clinical substantiation on the claim.

• 1. Evaluation and imaging: confirm the painful level, obtain advanced imaging demonstrating an active fracture, and document point tenderness and functional impairment.
• 2. Benefit and vendor check: identify the plan, whether augmentation is delegated (eviCore, Carelon, or another vendor), and the applicable policy edition and effective date.
• 3. Clinical assembly: compile the imaging report(s), symptom-onset date, conservative-care history or contraindication, pain scores, and the level-specific medical-necessity statement.
• 4. Submission: submit through the vendor portal or plan channel with the planned CPT/level detail (22513/22514 and any +22515 levels) and linked ICD-10-CM diagnoses.
• 5. Clinical review / peer-to-peer: if pended, provide the missing correlation element; be prepared for a peer-to-peer focused on fracture age, imaging activity, and level concordance.
• 6. Determination and scheduling: record the authorization number, approved level(s), and validity window; schedule within the authorized period and setting (ASC vs HOPD).
• 7. Post-service: ensure operative documentation matches the authorized levels and that coding reflects one primary code plus add-on levels.

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Reviewer Lens

Payer Perspective

Payer Perspective

A payer or delegated UM reviewer is usually evaluating three linked facts: whether advanced imaging proves an active fracture, whether the painful and tender level matches the imaged and requested level, and whether conservative management failed, was contraindicated, or was clinically inappropriate. Fracture age, imaging recency, and the planned device or technique can materially change the determination.

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Clinical Pearls

Clinical Pearls

Pearls

• One sentence linking symptom-onset date to imaging-confirmed edema resolves most acute-versus-chronic denials.
• Harmonized level language across note, imaging, and request eliminates discordance flags.
• A three-sentence peer-to-peer script (fracture age, imaging activity, level concordance) reverses most pends.

Pitfalls

• Multi-level coding errors (double primary codes) that trigger CCI-related denials.
• Wrong ICD-10 encounter character contradicting the 'acute fracture' narrative.
• Device/technique mismatches that convert a strong clinical case into a technique denial.

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GoHealthcare Perspective

GoHealthcare Perspective

GoHealthcare Leadership Perspective

Vertebral augmentation is a high-value, evidence-scrutinized service, which makes it an ideal test of an organization's documentation and utilization discipline. The programs that perform best treat the imaging-correlation statement and the fracture-age timeline as non-negotiable structured fields rather than free-text afterthoughts. The operational objective is not merely to obtain a single authorization; it is to build a record that survives post-payment audit. Because the underlying evidence base is genuinely contested, augmentation claims are attractive audit targets, and the same documentation that clears prior authorization also protects the earned revenue. AI-enabled workflow can now flag a missing edema statement, a wrong-encounter ICD-10 seventh character, or a device-versus-policy mismatch before submission. Deployed with human review, these checks convert avoidable denials into first-pass approvals and free clinical staff for genuine peer-to-peer defense.

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GoHealthcare Insights

GoHealthcare Insights

Drawn from GoHealthcare's experience supporting musculoskeletal specialty practices, the following operational patterns most reliably improve approval rates and reduce rework for vertebral augmentation.

• Write the imaging correlation into the note, not just the imaging order. Reviewers approve on the narrative in the clinical record; a radiology report buried in the chart without a corresponding clinician statement is the most common reason a strong case still pends.
• Time-stamp the fracture. A single sentence pairing symptom-onset date with the imaging-activity finding resolves the acute-versus-chronic question that drives most denials.
• Standardize the level language. Ensure the tender level, the imaged level, and the requested level are stated identically across the note, the imaging report, and the authorization request.
• Pre-clear the device. Reconcile the planned system against the policy edition at scheduling, particularly for radiofrequency or implant-based augmentation.

GoHealthcare Prior Authorization Insight

From the vantage point of a national MSK specialty MSO, the failure modes on augmentation requests are remarkably consistent, and almost all are documentation-timing failures rather than true coverage disputes.

What experienced PA teams do differently

• They build the request around the three correlation elements (tender level, active-fracture level, requested level) and put them in the first paragraph.
• They quote the imaging finding verbatim from the report (edema/uptake at the level) rather than paraphrasing it loosely.
• They confirm the policy edition and effective date before submitting, since augmentation policies are frequently re-versioned.
• They pre-identify the peer-to-peer physician and arm them with a three-sentence verbal summary.
• They run an internal QA pass for ICD-10 encounter specificity and neoplasm dual-coding before the claim drops.

Frequent provider mistakes

• Ordering imaging but never stating the correlation in the clinical note.
• Leaving symptom-onset undated, forcing the reviewer to assume a chronic fracture.
• Reporting 22513 and 22514 together instead of one primary plus +22515.
• Coding malignant VCF without the underlying-neoplasm code.
• Booking a policy-flagged technique/device without pre-clearance.

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FAQ

Frequently Asked Questions

What is the difference between kyphoplasty and vertebroplasty for coding?

Kyphoplasty includes deliberate cavity creation and is reported with 22513/22514/+22515; vertebroplasty injects cement without cavity creation and uses 22510/22511/+22512. The clinical documentation must support whichever technique is billed.

How are multiple levels coded?

Report one primary code for the first level (22513 if thoracic or 22514 if lumbar) and one unit of +22515 for each additional thoracic or lumbar level, even across regions and even if non-contiguous.

Can I bill 22513 and 22514 together?

No. Select a single primary code based on the first level treated; all additional levels are reported with +22515.

Is imaging guidance billed separately?

No. Fluoroscopic or CT guidance is bundled into the augmentation codes.

Is bone biopsy separately payable at the same level?

No. Bone biopsy (20225/20250/20251) at the augmented level is integral and not separately reported.

Does traditional Medicare require prior authorization?

Not for the professional service, but the applicable LCD medical-necessity criteria still apply at adjudication and on audit.

Which imaging finding matters most for approval?

Bone-marrow edema on MRI (or uptake on bone scan / SPECT-CT) at the symptomatic level, demonstrating an active fracture.

How recent must the imaging be?

Several LCDs expect advanced imaging within roughly 30 days of the planned procedure; verify the specific policy.

Is a fixed conservative-care duration required?

For acute/subacute VCF, policies generally favor early intervention rather than a mandatory multi-month trial; document that conservative care failed or is inappropriate and explain urgency.

Is kyphoplasty covered for cancer-related fractures?

Yes, as a palliative indication for painful malignant/osteolytic VCF refractory to conservative care, with the underlying neoplasm documented and coded.

How is cervical augmentation coded?

There is no Category I or III code; report unlisted spine procedure 22899 with documentation.

Is radiofrequency kyphoplasty covered?

Several payers consider radiofrequency kyphoplasty experimental/investigational; confirm coverage under the specific policy before scheduling.

Is SpineJack covered like balloon kyphoplasty?

Some payers (e.g., Aetna) explicitly recognize the SpineJack system as medically necessary for qualifying VCF; coverage may be device-specific, so verify the policy.

What place of service applies?

Commonly ASC (POS 24) or hospital outpatient; inpatient when clinically warranted. Device and cement costs are packaged into the facility payment.

What modifiers should not be used?

Do not append modifier 50 (the descriptor is unilateral or bilateral) and do not append 51 or 59 to the add-on +22515.

What are the most common denial reasons?

Failure to demonstrate an acute/active fracture, level discordance, missing conservative-care documentation, and technique/device mismatches.

Who typically manages commercial prior authorization?

Frequently eviCore or Carelon, depending on the plan; Cigna uses eviCore CMM-607 for vertebral augmentation and sacroplasty.

What ICD-10 code is used for a typical osteoporotic VCF?

M80.08XA (age-related osteoporosis with current pathological vertebral fracture, initial encounter) is the most common, with the correct 7th character for the encounter.

How should malignant VCF be coded?

Pair the pathological-fracture code (e.g., M84.58XA) with the underlying-neoplasm code (e.g., C41.2, C79.51, or C90.00).

Can multiple non-contiguous levels be treated and billed in one session?

Yes; report one primary plus +22515 per additional level regardless of contiguity, subject to documentation and MUE limits.

What is the single best way to avoid a peer-to-peer?

Put the fracture-age timeline and the imaging-level correlation in the first paragraph of the request so the reviewer never has to reconstruct them.

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Case Study

GoHealthcare Case Study

Educational scenario. No actual patient or organization is depicted.

Clinical scenario

A community pain practice requests kyphoplasty at L1 for an older adult with two weeks of severe, activity-limiting midline back pain after a minor fall. MRI shows an L1 compression fracture with STIR bone-marrow edema; examination shows focal L1 percussion tenderness.

Documentation challenges

The initial request attached the MRI order but not the report, listed 'back pain' without a level, and omitted the symptom-onset date and any conservative-care note.

Prior authorization barriers

The delegated UM vendor pended the request for insufficient evidence of an acute, active fracture and unclear level correlation, and offered a peer-to-peer.

Payer considerations

The plan's policy required advanced-imaging confirmation of an active fracture correlating with the symptomatic level and documentation that conservative care had failed or was inappropriate.

Operational workflow & resolution strategy

The MSO's PA team resubmitted with the MRI report language quoting L1 edema, a one-line symptom-onset statement (14 days), the L1 point-tenderness finding, and a note that prolonged immobilization and opioid escalation were inappropriate given fall risk and functional decline. The three level references (tender, imaged, requested) were harmonized to 'L1.'

Outcome

The request was approved on resubmission without a peer-to-peer. The claim later coded cleanly as a single primary 22514 with correct ICD-10 encounter specificity.

Lessons learned

• The clinical facts already supported approval; only the documentation packaging was missing.
• A pre-submission correlation-and-timeline gate would have produced a first-pass approval.

• Harmonized level language eliminated the discordance flag.

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Related Resources

Related Procedures and Resources

The table contrasts kyphoplasty with adjacent options that reviewers and clinicians weigh for painful VCF. It is an operational comparison, not a treatment recommendation.

Option	Cavity / Height Restoration	Primary CPT	Typical Role
Kyphoplasty (balloon augmentation)	Yes - cavity created, height/deformity often partially restored	22513 / 22514 / +22515	Painful acute/subacute osteoporotic or malignant VCF; deformity correction desired.
Vertebroplasty	No cavity creation; cement injected into cancellous bone	22510 / 22511 / +22512	Painful VCF where cavity creation is not required; addressed in the companion vertebroplasty guide.
Mechanical implant augmentation (e.g., SpineJack)	Yes - controlled height restoration via implant	22513 / 22514 / +22515 (device-specific)	Selected fractures where greater height control is sought; coverage may be device-specific.

Option	Cavity / Height Restoration	Primary CPT	Typical Role
Conservative management	No	N/A	Analgesia, bracing, activity modification; the comparator against which augmentation medical necessity is judged.
Basivertebral nerve ablation (Intracept)	N/A - treats vertebrogenic pain, not fracture	64628 / +64629	Chronic vertebrogenic low back pain with Modic changes; a different indication entirely (companion guide).

• GoHealthcare MSK Specialty Procedure Library - Vertebroplasty (companion guide).
• GoHealthcare MSK Specialty Procedure Library - Basivertebral Nerve Ablation / Intracept (companion guide).
• GoHealthcare Revenue Cycle Knowledge Center - OPPS/ASC packaging, NCCI, and MUE reference.
• GoHealthcare Prior Authorization Playbooks - imaging-correlation and peer-to-peer templates.
• Website: https://www.gohealthcarellc.com

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References

References and Reading Recommendations

• Centers for Medicare & Medicaid Services. Medicare Coverage Database (LCDs, LCAs, NCDs). https://www.cms.gov/medicare-coverage-database
• CMS. LCD: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) - e.g., L33569, L34228, L34976, L35130, L38213, L38737. https://www.cms.gov/medicare-coverage-database
• CMS. Billing and Coding Articles A57630, A57752, A57872 (PVA for VCF). https://www.cms.gov/medicare-coverage-database
• Aetna. Clinical Policy Bulletin 0016: Back Pain - Invasive Procedures. https://www.aetna.com/cpb/medical/data/1_99/0016.html
• UnitedHealthcare. Medical Policy: Percutaneous Vertebroplasty and Kyphoplasty. https://www.uhcprovider.com/en/policies-protocols.html
• eviCore by Evernorth. Clinical Guideline CMM-607: Primary Vertebral Augmentation (Percutaneous Vertebroplasty-Kyphoplasty) and Sacroplasty. https://www.evicore.com/provider/clinical-guidelines
• Carelon Medical Benefits Management. Musculoskeletal / Spine Surgery Clinical Guidelines. https://www.carelonmedicalbenefitsmanagement.com
• American Medical Association. Current Procedural Terminology (CPT(R)) 2026. https://www.ama-assn.org/practice-management/cpt
• Wardlaw D, et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE). Lancet. 2009;373(9668):1016-1024.
• Clark W, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR). Lancet. 2016;388:1408-1416.
• Berenson J, et al. Balloon kyphoplasty versus non-surgical fracture management for cancer-related vertebral fractures (CAFE). Lancet Oncol. 2011;12(3):225-235.
• Buchbinder R, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361(6):557-568.
• Kallmes DF, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361(6):569-579.
• Noriega D, et al. Titanium implantable vertebral augmentation device versus balloon kyphoplasty (SAKOS). The Spine Journal. 2019;19(11):1782-1795.
• U.S. Food & Drug Administration. 510(k) Premarket Notification Database. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm
• North American Spine Society (NASS). Coverage Policy Recommendations. https://www.spine.org

• The applicable MAC LCD and Billing/Coding Article for the patient's jurisdiction and date of service (primary source for Medicare medical necessity).
• The effective-dated commercial policy in force for the specific plan (eviCore CMM-607, UnitedHealthcare, Aetna CPB 0016, Carelon, or the applicable BCBS policy).
• Multisociety and specialty-society statements on vertebral augmentation (e.g., ACR/ASNR/ASSR/SIR/SNIS; NASS coverage recommendations).
• The device manufacturer's current instructions-for-use and coding/payment guide for the specific system planned.

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Disclaimer

Standard Disclaimer

Educational and Operational Disclaimer

This document is intended for educational and operational reference purposes only. It does not replace physician clinical judgment, payer policy review, legal advice, or official CMS guidance. Coverage policies, coding guidance, and reimbursement requirements should always be verified with the applicable payer and current regulatory sources before a claim is submitted. Procedure-specific technique, device selection, and patient care decisions remain the responsibility of the treating physician.

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Pinky Maniri

Founder and Chief Executive Officer, GoHealthcare Practice Solutions

Healthcare operations, MSK prior authorization, revenue-cycle strategy, compliance, and healthcare AI governance.

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