Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty - (Effective Date - 2026-10-15) 6.01.17

By October 15, 2026: Billing and clinical teams must implement the following changes: (1) Update prior authorization (PA) requirements in billing software to mandate documentation of 4-week conservative treatment trial (prescription analgesics/steroids/NSAIDs AND provider-directed exercise) for non-malignant vertebral compression fractures, unless contraindicated with written explanation; (2) Require documentation that osteoporotic compression fracture patients are enrolled in osteoporosis treatment/prevention program before claim submission; (3) Update clinical documentation templates and encounter forms to require providers to document acute (0-6 weeks) vs. subacute (>6 weeks) pain status and functional impairment level; (4) Train providers and billing staff that sacroplasty is now investigational and will be denied for all indications; (5) Configure system edits to flag and deny claims for vertebroplasty at cervical spine (C-spine), T1-T4 thoracic levels, or >2 spinal levels per date of service; (6) Create internal communication to providers documenting contraindications that exempt patients from conservative treatment requirement (coagulation disorders, myelopathy, burst fractures, active infections, etc.) and establish process for provider documentation of contraindications; (7) Verify all claims submitted after October 15, 2026 include detailed conservative treatment documentation and imaging reports interpreted by independent radiologist; (8) Denial risk is high: claims lacking required conservative treatment documentation or missing osteoporosis program enrollment confirmation will be denied as not meeting medical necessity.