Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty 6.01.17

By October 15, 2025: Billing team must implement prior authorization requirement for all vertebroplasty, kyphoplasty, and mechanical vertebral augmentation procedures before claim submission. Update billing system and encounter forms to enforce: (1) mandatory documentation of 4+ weeks of failed conservative treatment (prescription analgesics, steroids, NSAIDs, and provider-directed exercise program) unless contraindicated, (2) independent radiologist imaging reports (CT/MRI/Myelography) with reconciliation of any discrepancies with surgeon interpretation, (3) verification that procedure involves maximum 2 levels within T5-L5 spine, (4) documentation of clinically significant functional impairment and pain level meeting policy thresholds, and (5) for osteoporotic fractures, confirmation of osteoporosis treatment program enrollment. Providers must document whether fracture is acute (0-6 weeks) or subacute (>6 weeks) with corresponding pain/functional impairment justification. Flag all sacroplasty claims as investigational (non-covered) and deny reimbursement when vertebroplasty/kyphoplasty is billed with any open spine procedure code. Claims lacking required documentation or prior authorization will be denied. Coordinate with clinical staff and providers to establish documentation templates and pre-authorization submission workflows.