GoHealthcare MSK Specialty Procedure Library

Vertebroplasty

Percutaneous vertebroplasty 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

Vertebroplasty stabilizes a painful vertebral compression fracture through direct cement injection without cavity creation. The operational challenge is twofold: the record must establish an acute or subacute, imaging-active, symptomatic fracture despite an evidence base that receives heightened payer scrutiny, and the operative language must remain consistent with the vertebroplasty code family.

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

Percutaneous vertebroplasty is an image-guided, minimally invasive procedure in which bone cement (polymethylmethacrylate, PMMA, or a comparable cleared material) is injected directly into a fractured vertebral body to stabilize the fracture and reduce pain. Unlike kyphoplasty, vertebroplasty involves no cavity creation and makes no attempt to restore vertebral height. This single distinction - cavity creation - determines the entire CPT code family and is the pivot for correct coding.

Domain	Summary Position (verify per payer / date of service)
Medicare NCD	No National Coverage Determination specific to vertebroplasty. Coverage is governed by MAC Local Coverage Determinations (LCD) and companion Local Coverage Articles (LCA).
Medicare LCD	Governed by the same Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) LCD family that covers kyphoplasty (e.g., L33569, L34228, L34976, L35130, L38213, L38737; articles A57630, A57752, A57872). Vertebroplasty and kyphoplasty are addressed together.
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). Sacroplasty (a related procedure) is frequently considered investigational and is generally non-covered by CMS.
Evidence level	Genuinely contested and specifically scrutinized for vertebroplasty. Two sham-controlled RCTs (Buchbinder; Kallmes/INVEST, NEJM 2009) were negative but enrolled mostly non-acute fractures; VAPOUR (Lancet 2016) was positive for acute (under 6 weeks) severe pain; VERTOS II (open-label, Lancet 2010) positive; VERTOS IV (BMJ 2018) showed improvement in both arms without a significant difference. A multisociety position statement supports augmentation in selected patients, and registry meta-analyses suggest a mortality benefit.
Image guidance	Fluoroscopy or CT guidance is inherent and bundled into the CPT descriptors (not separately reportable).
Prior authorization	Commonly required by commercial and Medicare Advantage plans, frequently delegated to eviCore (CMM-607) or Carelon. Traditional Medicare does not prior-authorize the professional service but enforces LCD criteria at adjudication.
Conservative therapy	Documented failure of, contraindication to, or intolerance of non-surgical management is expected; the acute-severe-pain pathway (VAPOUR selection) shortens the practical conservative interval.
Key imaging	Advanced imaging showing an active/edematous fracture (MRI STIR bone-marrow edema, or bone scan / SPECT-CT uptake) correlating with the symptomatic level is the decisive medical-necessity element - and matters even more given the evidence debate.
Coding snapshot	22510 (cervicothoracic), 22511 (lumbosacral), +22512 (each additional cervicothoracic or lumbosacral level). Cervical vertebroplasty is reportable under 22510; there is no separate cavity-creation step. Bone biopsy and imaging guidance are bundled.
Typical approval driver	Acute/subacute, imaging-active fracture at a level that matches point tenderness and the requested level, with 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. Painful VCFs drive immobility, progressive deformity, reduced pulmonary function, opioid exposure, and, in older adults, measurable increases in morbidity and mortality. Vertebroplasty is a percutaneous, image-guided stabilization procedure intended to relieve fracture-related pain and prevent further collapse by reinforcing the vertebral body with injected cement. Mechanistically, one or two needles are advanced into the vertebral body (typically transpedicular). Bone cement is injected directly into the cancellous bone under imaging guidance. Crucially, vertebroplasty does not create a cavity

and does not attempt to restore vertebral height; the analgesic and stabilizing effect derives from mechanical reinforcement of the fractured bone. This is the defining contrast with kyphoplasty, in which a mechanical device creates a cavity (and often partially restores height) before cementation. The distinction is not merely clinical - it maps directly to two different CPT code families, and the operative note must make clear which was performed. This guide is written for the teams that must consistently obtain authorization and clean reimbursement: 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. Given the unusually public evidence debate around vertebroplasty, disciplined patient selection and documentation matter more here than for almost any other spine procedure.

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04

Clinical Foundation

Relevant Anatomy

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

• Thoracolumbar junction (T11-L2) is the most common osteoporotic VCF site due to the biomechanical transition from the rigid thoracic cage to the mobile lumbar spine.
• Cancellous vertebral core is the target of cement injection; cement interdigitates with trabecular bone to mechanically reinforce the fractured body (no cavity is created).
• Posterior vertebral body wall integrity is a central safety and selection consideration; cortical disruption or retropulsion raises the risk of cement extravasation into the canal, which is a particular concern in the low-pressure, direct-injection technique.
• Spinal cord, conus medullaris, and exiting nerve roots lie immediately posterior to the body, underlying the imaging emphasis on posterior wall status and canal compromise.

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05

Clinical Foundation

Clinical Indications

Vertebroplasty is generally indicated for a painful vertebral body compression fracture that correlates with clinical findings and advanced imaging, when the fracture is the dominant pain generator and height restoration is not a treatment goal. Recognized indication categories:

• 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. The strongest randomized support (VAPOUR) is in the acute, severe-pain population.
• Malignant / osteolytic VCF from primary bone malignancy, multiple myeloma, or metastatic disease, causing painful vertebral collapse refractory to conservative care (a recognized palliative indication).
• VCF refractory to, or inappropriate for, non-surgical management, where prolonged immobilization, bracing, or systemic analgesia would carry unacceptable risk.
• Cervical, thoracic, or lumbosacral levels may be treated; unlike kyphoplasty, vertebroplasty has a cervical code (22510 includes cervicothoracic).

GoHealthcare Clinical Insight

Because vertebroplasty is the procedure most associated with negative sham-controlled trials, the indication narrative should lean explicitly on the features those trials lacked: a genuinely acute fracture (dated symptom onset), imaging-confirmed edema at the treated level, and severe, disabling pain. That triad mirrors the VAPOUR selection and is exactly what reviewers look for.

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06

Clinical Foundation

Patient Selection

Selection discipline is the single greatest determinant of both outcome and approval for vertebroplasty. Documentation should show 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 (validated pain score plus 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 vertebroplasty would not address.
• Intact or adequately assessed posterior vertebral body wall to support safe, low-pressure cement injection.

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07

Clinical Foundation

Contraindications and Precautions

• 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 wall disruption with canal compromise (higher extravasation risk given direct injection); severe vertebra plana limiting access; radiculopathy or myelopathy as the dominant symptom; correctable coagulopathy.
• 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 vertebroplasty 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. Reviewers evaluate concordance among symptoms, examination, and advanced imaging, not merely the presence of a fracture on a film - and they apply that scrutiny more rigorously to vertebroplasty because of the sham-controlled literature.

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 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

As with kyphoplasty, vertebral augmentation for acute VCF is time-sensitive: the evidence and most policies favor early intervention in appropriately selected patients rather than a mandatory multi-month conservative trial. The record should 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

The acute/severe-pain framing does double duty for vertebroplasty: it aligns with the strongest randomized evidence (VAPOUR) and it preempts the reviewer's instinct to cite the negative sham-controlled trials, which enrolled largely non-acute fractures.

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10

Coverage and Medical Necessity

Diagnostic Prerequisites and Treatment Sequencing

Imaging is the decisive medical-necessity element. 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 cement injection.

• 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.
• CT: best defines posterior wall integrity, retropulsion, and cortical detail - particularly important before direct cement injection.
• 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 vertebroplasty. Medicare coverage is administered through the applicable MAC Local Coverage Determination and companion Billing and Coding Article. The absence of an NCD does not remove medical-necessity, documentation, coding, or audit requirements.

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 for vertebroplasty; coverage is administered through MAC Local Coverage Determinations and their companion Billing and Coding Articles. Vertebroplasty and kyphoplasty are addressed together in the PVA-for-VCF LCD family, and their medical-necessity criteria are closely aligned across MACs. The synthesis below reflects common positions (for example, L33569, L34228, L34976, L35130, L38213, L38737; 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 (supervision and interpretation) and, where applicable, moderate sedation are bundled into the vertebroplasty codes.
• The assistant-at-surgery Medicare payment indicator for these codes is 1; an assistant at surgery is not payable.
• CMS generally does not cover sacral augmentation/sacroplasty (Category III 0200T/0201T); where non-covered, obtain an Advance Beneficiary Notice (ABN) before the procedure for Medicare patients.
• 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 vertebroplasty, but the reasonable-and-necessary standard still applies at adjudication and on audit - and vertebroplasty claims are attractive audit targets precisely because of the contested evidence. Build the record as though it will be reviewed: an imaging report documenting edema/uptake at the treated level, a dated symptom-onset note, and a level-specific medical-necessity statement in the operative record.

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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 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 percutaneous polymethylmethacrylate vertebroplasty 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 vertebroplasty 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 policies cover percutaneous vertebroplasty for qualifying VCF; percutaneous sacroplasty is frequently considered investigational, and radiofrequency techniques may be restricted - verify the specific policy.

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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' addresses vertebroplasty and kyphoplasty together; coverage for painful osteoporotic and malignant VCF with imaging correlation. Policy versions are dated (an edition 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; vertebroplasty 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 for vertebroplasty, kyphoplasty, 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 vertebroplasty evidence base is contested. The source guide distinguishes negative sham-controlled trials that largely enrolled non-acute fractures from favorable evidence in carefully selected patients with acute, severe, imaging-active fractures. This distinction is operationally important for documentation, appeal, and peer-to-peer preparation, but clinical evidence must remain separate from controlling payer coverage criteria.

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

• Clark W, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR). Lancet. 2016;388(10052):1408-1416.
• 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 (INVEST). N Engl J Med. 2009;361(6):569-579.
• Klazen CA, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (VERTOS II). Lancet. 2010;376(9746):1085-1092.
• Barr JD, Jensen ME, Hirsch JA, et al. Position Statement on Percutaneous Vertebral Augmentation: A Consensus Statement (SIR, AANS/CNS, ACR, ASNR, ASSR, CIRA, SNIS). J Vasc Interv Radiol. 2014;25(2):171-181.
• 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 vertebroplasty. Medicare coverage is administered through the applicable MAC Local Coverage Determination and companion Billing and Coding Article. The absence of an NCD does not remove medical-necessity, documentation, coding, or audit requirements.

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' addresses vertebroplasty and kyphoplasty together; coverage for painful osteoporotic and malignant VCF with imaging correlation. Policy versions are dated (an edition 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; vertebroplasty 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 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 percutaneous polymethylmethacrylate vertebroplasty 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 for vertebroplasty, kyphoplasty, and sacroplasty; spine-related services are eviCore-delegated for applicable plans.
Humana	PA per plan / MA	Covers vertebroplasty 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 policies cover percutaneous vertebroplasty for qualifying VCF; percutaneous sacroplasty is frequently considered investigational, and radiofrequency techniques may be restricted - verify the specific policy.

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17

Prior Authorization

Prior Authorization Requirements

A complete vertebroplasty request should include the dated fracture timeline, advanced imaging demonstrating edema or uptake at the symptomatic level, matching examination findings, severity and functional limitations, conservative-care failure or urgency rationale, the requested codes and levels, and an explicit cement-only plan without cavity creation. Sacral cases and device-dependent techniques require separate coverage review.

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 vertebroplasty 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 (extravasation-risk assessment)
• Point tenderness documented at the corresponding level on examination
• Conservative care attempted, contraindicated, or inappropriate, with urgency rationale
• Operative note states cement injection WITHOUT cavity creation (supports 22510-22512 family)
• 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
• 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, these operational patterns most reliably improve approval rates and reduce rework for vertebroplasty.

• Anchor to the acute-severe-pain population. Vertebroplasty is uniquely exposed to efficacy challenges; the note that dates symptom onset and quotes imaging edema at the treated level preempts the reviewer's strongest objection.
• Say 'no cavity' out loud. An operative note that explicitly states cement injection without cavity creation keeps the case cleanly in the 22510-22512 family and prevents a code-family mismatch.
• 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.
• Separate sacroplasty expectations. Sacral cases follow a different (and often non-covered) coding and coverage path; flag them early so scheduling and billing are aligned.

Pearls

• One sentence linking symptom-onset date to imaging-confirmed edema resolves most acute-versus-chronic and efficacy denials.
• An explicit 'no cavity created' operative statement locks in the correct code family.
• Reframing efficacy to the acute, severe-pain population turns the strongest objection into the strongest argument.

Pitfalls

• Code-family mismatches when cavity language contradicts a vertebroplasty claim.
• Wrong ICD-10 encounter character contradicting the 'acute fracture' narrative.
• Assuming sacroplasty coverage; it is generally non-covered by CMS and often investigational.

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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 vertebroplasty.

• Cavity creation is the determining factor. No cavity created (cement injection only) = vertebroplasty (22510/22511/+22512). Cavity created with a mechanical device = augmentation (22513/22514/+22515). The operative note must make this unambiguous.
• Report exactly one primary code per session (22510 cervicothoracic or 22511 lumbosacral) plus one unit of +22512 for each additional cervicothoracic or lumbosacral body - even across regions and even if non-contiguous.
• Do not report 22510 and 22511 together; the first level treated selects the single primary code by its region, and all further levels are +22512.
• Imaging guidance (S&I) and bone biopsy at the same level are bundled; do not unbundle.
• Place of service is typically the ASC (24) or hospital outpatient (19/22); inpatient (21) when clinically warranted. Cement and delivery-instrument costs are packaged into the facility payment.

CPT(R)	Descriptor (abbreviated)	Coding Notes
22510	Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, incl. all imaging guidance; cervicothoracic	Primary code when the first level treated is cervical or thoracic. One primary per session.
22511	Same as above; lumbosacral	Primary code when the first level treated is lumbar or sacral. Do not report with 22510 for a second level - use +22512.

CPT(R)	Descriptor (abbreviated)	Coding Notes
+22512	Same as above; each additional cervicothoracic or lumbosacral vertebral body (list separately in addition to primary)	Add-on for every additional level, any region, contiguous or not. Do not append modifier 51 or 59.
0200T / 0201T	Percutaneous sacral augmentation (sacroplasty), unilateral / bilateral injection(s), incl. imaging guidance and bone biopsy	Category III codes for sacroplasty; generally non-covered by CMS and frequently investigational commercially. Do not use for thoracolumbar vertebroplasty.

Bundling reminders. Do not separately report bone biopsy (20225/20250/20251) at the same level, imaging guidance, or moderate sedation. Do not report 22510-22512 with 20225, 22310, 22315, 22325, or 22327 at the same level.

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

• Bone cement, vertebroplasty needles/cannulae, and delivery systems 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 vertebroplasty. Selection depends on etiology (osteoporotic, malignant, traumatic), encounter type (initial / subsequent / sequela), and vertebral region. 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 collapse is not attributable to osteoporosis (M80.-), neoplasm (M84.58-), or trauma (S22.- / S32.-), each an Excludes1.

ICD-10-CM	Description	Notes
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

For vertebroplasty, the two highest-frequency errors are (1) a 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. A third, procedure-specific error is letting 'cavity' language creep into the operative note, which invites a mismatch with the vertebroplasty code family.

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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 injection'; do not append 50. LT/RT are not required.
51 (multiple procedures)	Do not append to +22512	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, separately reportable service.
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 vertebroplasty.

• Cavity creation is the determining factor. No cavity created (cement injection only) = vertebroplasty (22510/22511/+22512). Cavity created with a mechanical device = augmentation (22513/22514/+22515). The operative note must make this unambiguous.
• Report exactly one primary code per session (22510 cervicothoracic or 22511 lumbosacral) plus one unit of +22512 for each additional cervicothoracic or lumbosacral body - even across regions and even if non-contiguous.
• Do not report 22510 and 22511 together; the first level treated selects the single primary code by its region, and all further levels are +22512.
• Imaging guidance (S&I) and bone biopsy at the same level are bundled; do not unbundle.
• Place of service is typically the ASC (24) or hospital outpatient (19/22); inpatient (21) when clinically warranted. Cement and delivery-instrument costs are packaged into the facility payment.

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Reimbursement

Reimbursement Considerations

Report one primary vertebroplasty code per session - 22510 when the first treated level is cervical or thoracic or 22511 when it is lumbar or sacral - plus +22512 for each additional level. Imaging guidance and bone biopsy at the treated level are included. Cement and delivery supplies are generally packaged into facility payment. Sacroplasty follows a separate Category III coding and coverage pathway. Verify current OPPS or ASC status, MUEs, NCCI edits, payer contract terms, 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 intake template requiring symptom-onset date, imaging-activity statement, and level correlation before submission.
• Attach the advanced-imaging report (not just the order) to every request.
• Require an explicit 'cement injection without cavity creation' statement in vertebroplasty operative notes.
• Pre-load the acute-fracture / multisociety-position framing for anticipated efficacy objections.
• Screen sacral cases separately given sacroplasty non-coverage.
• Run a coder QA pass for one-primary-plus-add-on structure, code-family alignment, ICD-10 encounter specificity, and neoplasm dual-coding.

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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.
Efficacy / evidence challenge	Reviewer cites negative sham-controlled trials	Frame the case to the acute, severe-pain population (VAPOUR selection) and cite the multisociety position statement supporting augmentation in selected patients.
Chronic / healed fracture	Symptom duration or imaging suggests a non-active fracture	Document current pain, recent imaging activity, and any progression; address the 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.
Wrong procedure family coded	Cavity-creation language implies augmentation, not vertebroplasty	Ensure the operative note and code family agree (no cavity = 22510-22512).
Sacroplasty non-coverage	Sacral augmentation billed as covered	Recognize that sacroplasty (0200T/0201T) is generally non-covered by CMS and often investigational commercially.

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Appeals

Appeals, Reconsideration, and Peer-to-Peer

Most vertebroplasty denials are correlation, timing, or efficacy denials. Effective appeals restore the missing linkage and reframe the case to the population where the evidence is strongest.

• 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.
• For efficacy denials, cite the acute-severe-pain evidence (VAPOUR) and the multisociety position statement, and distinguish the negative sham trials by their non-acute enrollment.
• 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.

GoHealthcare Best Practices

The strongest vertebroplasty appeal reframes the debate: the question is not whether vertebroplasty works in general, but whether it works in this acute, imaging-active, severe-pain patient - the exact population in which the randomized evidence is favorable.

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Operations

Operational Workflow

This 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 vertebroplasty is delegated (eviCore CMM-607, 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 (22510/22511 and any +22512 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 that may cite the sham-controlled trials - counter with the acute-fracture selection and imaging activity.
• 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 the operative note states that cement was injected without cavity creation (supporting the vertebroplasty code family) and that coding reflects one primary plus add-on levels.

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Reviewer Lens

Payer Perspective

Payer Perspective

Reviewers typically focus on fracture acuity, imaging activity, level concordance, severity and functional impairment, and whether conservative management failed or was inappropriate. Because vertebroplasty has a highly visible evidence controversy, the record should clearly establish an acute or subacute, imaging-active fracture and explicitly distinguish cement injection without cavity creation from balloon or mechanical augmentation.

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Clinical Pearls

Clinical Pearls

Pearls

• One sentence linking symptom-onset date to imaging-confirmed edema resolves most acute-versus-chronic and efficacy denials.
• An explicit 'no cavity created' operative statement locks in the correct code family.
• Reframing efficacy to the acute, severe-pain population turns the strongest objection into the strongest argument.

Pitfalls

• Code-family mismatches when cavity language contradicts a vertebroplasty claim.
• Wrong ICD-10 encounter character contradicting the 'acute fracture' narrative.
• Assuming sacroplasty coverage; it is generally non-covered by CMS and often investigational.

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GoHealthcare Perspective

GoHealthcare Perspective

GoHealthcare Leadership Perspective

Vertebroplasty is the clearest example in the MSK portfolio of a procedure whose reimbursement depends less on whether it is covered and more on whether the record proves the patient belongs to the population in which it works. Organizations that internalize that distinction convert a contested procedure into a predictable one. Because the evidence base is publicly debated, vertebroplasty claims draw audit attention. The same documentation discipline that clears prior authorization - dated acute fracture, imaging edema at the treated level, level concordance, and a clean 'no cavity' operative statement - is what protects the earned revenue on post-payment review. AI-enabled review at the point of request can now flag a missing edema statement, a wrong-encounter ICD-10 character, a code-family mismatch, or an inadvertently billed sacroplasty. Deployed with human oversight, these checks turn avoidable denials into first-pass approvals.

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GoHealthcare Insights

GoHealthcare Insights

Drawn from GoHealthcare's experience supporting musculoskeletal specialty practices, these operational patterns most reliably improve approval rates and reduce rework for vertebroplasty.

• Anchor to the acute-severe-pain population. Vertebroplasty is uniquely exposed to efficacy challenges; the note that dates symptom onset and quotes imaging edema at the treated level preempts the reviewer's strongest objection.
• Say 'no cavity' out loud. An operative note that explicitly states cement injection without cavity creation keeps the case cleanly in the 22510-22512 family and prevents a code-family mismatch.
• 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.
• Separate sacroplasty expectations. Sacral cases follow a different (and often non-covered) coding and coverage path; flag them early so scheduling and billing are aligned.

GoHealthcare Prior Authorization Insight

From the vantage point of a national MSK specialty MSO, vertebroplasty requests fail in predictable ways, and almost all failures are documentation, timing, or code-family issues 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 place them in the first paragraph.
• They anticipate the efficacy objection and pre-load the acute-fracture selection and the multisociety position statement.
• They confirm the operative plan is cement-only (vertebroplasty) versus cavity-creation (augmentation) so the code family is correct from the start.
• They verify the policy edition and effective date before submitting.
• They screen sacral cases separately, knowing sacroplasty is generally non-covered by CMS.

Frequent provider mistakes

• Ordering imaging but never stating the correlation in the clinical note.
• Leaving symptom-onset undated, inviting a chronic-fracture reading and an efficacy denial.
• Reporting 22510 and 22511 together instead of one primary plus +22512.
• Letting cavity-creation language into a vertebroplasty operative note.
• Billing sacroplasty (0200T/0201T) as if it were routinely covered.

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FAQ

Frequently Asked Questions

What is the difference between vertebroplasty and kyphoplasty?

Vertebroplasty injects cement without creating a cavity or restoring height (22510/22511/+22512); kyphoplasty creates a cavity with a mechanical device and often partially restores height (22513/22514/+22515). Cavity creation is the determining coding factor.

Can vertebroplasty be performed and billed at a cervical level?

Yes. Cervical and thoracic levels are reported with 22510 (cervicothoracic). This differs from kyphoplasty, which has no cervical code.

How are multiple levels coded?

Report one primary code for the first level (22510 if cervicothoracic or 22511 if lumbosacral) and one unit of +22512 for each additional level, even across regions and even if non-contiguous.

Can I bill 22510 and 22511 together?

No. Select a single primary code based on the first level treated; all additional levels are reported with +22512.

Is imaging guidance billed separately?

No. Fluoroscopic or CT guidance (supervision and interpretation) is bundled into the vertebroplasty codes.

Is bone biopsy separately payable at the same level?

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

Does the evidence controversy affect coverage?

It affects scrutiny. The negative sham-controlled trials enrolled mostly non-acute fractures; coverage is most secure when the record documents an acute, imaging-active, severe-pain fracture (the VAPOUR population).

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 vertebroplasty 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.

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.

How is sacroplasty coded and covered?

Sacral augmentation (sacroplasty) uses Category III codes 0200T (unilateral) and 0201T (bilateral); it is generally non-covered by CMS and frequently considered investigational commercially.

What place of service applies?

Commonly ASC (POS 24) or hospital outpatient; inpatient when clinically warranted. Cement and delivery-instrument 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 +22512.

What are the most common denial reasons?

Failure to demonstrate an acute/active fracture, efficacy/evidence challenges, level discordance, missing conservative-care documentation, and code-family mismatches.

Who typically manages commercial prior authorization?

Frequently eviCore (CMM-607) or Carelon, depending on the plan; Cigna uses eviCore for vertebroplasty, kyphoplasty, 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 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).

What operative-note language best protects the vertebroplasty claim?

An explicit statement that cement was injected into the vertebral body without cavity creation, with the treated level(s) named.

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

Put the acute-fracture timeline and the imaging-level correlation in the first paragraph of the request so the reviewer never has to reconstruct them or reach for the sham-trial objection.

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Case Study

GoHealthcare Case Study

Educational scenario. No actual patient or organization is depicted.

Clinical scenario

A pain practice requests vertebroplasty at T8 for an older adult with three weeks of severe, activity-limiting mid-back pain after a minor fall. MRI shows a T8 compression fracture with STIR bone-marrow edema; examination shows focal T8 percussion tenderness.

Documentation challenges

The initial request listed 'compression fracture, back pain' without a level, omitted the symptom-onset date, and did not distinguish vertebroplasty from augmentation, creating ambiguity about the intended code family.

Prior authorization barriers

The delegated UM vendor pended the request, citing insufficient evidence of an acute, active fracture and referencing the sham-controlled literature; a peer-to-peer was offered.

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 T8 edema, a one-line symptom-onset statement (21 days), the T8 point-tenderness finding, a note that opioid escalation and prolonged immobilization were inappropriate given fall risk, and an explicit statement that the plan was cement injection without cavity creation. For the peer-to-peer, the physician was given a three-sentence summary emphasizing the acute, severe-pain (VAPOUR-type) selection.

Outcome

The request was approved after a brief peer-to-peer. The claim coded cleanly as a single primary 22510 (cervicothoracic, T8) with correct ICD-10 encounter specificity.

Lessons learned

• The clinical facts supported approval; documentation packaging and code-family clarity were the gap.
• Anticipating the efficacy objection with the acute-fracture narrative shortened the peer-to-peer.
• The explicit 'no cavity' statement kept the case in the correct code family.

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Related Resources

Related Procedures and Resources

The table contrasts vertebroplasty 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
Vertebroplasty	No cavity; cement injected into cancellous bone; no height restoration	22510 / 22511 / +22512	Painful acute/subacute osteoporotic or malignant VCF where cavity creation is not required; cervical level reportable.
Kyphoplasty (balloon augmentation)	Yes - cavity created, height/deformity often partially restored	22513 / 22514 / +22515	Painful VCF where cavity creation / deformity correction is desired; companion guide.
Sacroplasty	Sacral augmentation (with or without cavity)	0200T / 0201T (Category III)	Painful sacral insufficiency fracture; generally non-covered by CMS and often investigational.
Conservative management	No	N/A	Analgesia, bracing, activity modification; the comparator against which vertebroplasty 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 - Kyphoplasty (companion guide).
• GoHealthcare MSK Specialty Procedure Library - Basivertebral Nerve Ablation / Intracept (companion guide).
• GoHealthcare Revenue Cycle Knowledge Center - OPPS/ASC packaging, APC assignment, NCCI, and MUE reference.
• GoHealthcare Prior Authorization Playbooks - acute-fracture framing 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
• Clark W, et al. Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR). Lancet. 2016;388(10052):1408-1416.
• 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 (INVEST). N Engl J Med. 2009;361(6):569-579.
• Klazen CA, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (VERTOS II). Lancet. 2010;376(9746):1085-1092.
• Firanescu CE, et al. Vertebroplasty versus sham procedure for painful acute osteoporotic vertebral compression fractures (VERTOS IV). BMJ. 2018;361:k1551.
• Barr JD, Jensen ME, Hirsch JA, et al. Position Statement on Percutaneous Vertebral Augmentation: A Consensus Statement (SIR, AANS/CNS, ACR, ASNR, ASSR, CIRA, SNIS). J Vasc Interv Radiol. 2014;25(2):171-181.
• 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).
• The multisociety Position Statement on Percutaneous Vertebral Augmentation and the key randomized trials (VAPOUR, VERTOS II/IV, Buchbinder, Kallmes) for peer-to-peer preparation.
• The cement/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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