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Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty
Effective date
Oct 1, 2026
Identified
Jul 7, 2026
Summary
New medical policy (SUR107) effective October 1, 2026, establishes coverage criteria for percutaneous vertebroplasty, kyphoplasty, sacroplasty, and coccygeoplasty. Coverage is limited to treatment of no more than three symptomatic vertebral fractures (T5-L5 spine) when conservative therapy fails and specific clinical criteria are met. Procedures on other spinal levels, for sacral/coccygeal insufficiency fractures, and using non-balloon mechanical devices are classified as investigational and non-covered.
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What to do
Action · 7 steps
01Before October 1, 2026: Billing and clinical teams must implement the following.
02Update prior authorization protocols to require all seven documentation elements (imaging, pain correlation, functional impairment specifics, conservative therapy trial details, contraindication assessment, fracture location, and laterality) before claims are submitted.
03Configure billing system to flag and deny claims for procedures on cervical spine, T1-T5 thoracic levels, sacrum, or coccyx as investigational/non-covered.
04Establish internal verification process to confirm no more than three vertebral levels are treated per single date of service.
05Create provider education materials emphasizing six-week minimum conservative therapy requirement (NSAIDs/analgesics, physical therapy, activity modification) with documented response before procedure authorization.
06Update encounter templates to include specific instrumental ADL documentation fields (feeding, bathing, dressing, grooming, meal prep, household chores, occupational tasks) with description of functional limitation.
07Modify prior auth denial templates to specify if claim is rejected for: investigational indication, inadequate conservative therapy documentation, exceeding three-level limit, contraindications present, or spinal level outside T5-L5.
If missed: Failure to implement will result in claim denials and potential member billing liability.
Original notice
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty
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