Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Before October 1, 2026: Billing and clinical teams must implement the following: (1) Update 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. (2) Configure billing system to flag and deny claims for procedures on cervical spine, T1-T5 thoracic levels, sacrum, or coccyx as investigational/non-covered. (3) Establish internal verification process to confirm no more than three vertebral levels are treated per single date of service. (4) Create provider education materials emphasizing six-week minimum conservative therapy requirement (NSAIDs/analgesics, physical therapy, activity modification) with documented response before procedure authorization. (5) Update encounter templates to include specific instrumental ADL documentation fields (feeding, bathing, dressing, grooming, meal prep, household chores, occupational tasks) with description of functional limitation. (6) Modify 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. Failure to implement will result in claim denials and potential member billing liability.