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Excellus BlueCross BlueShieldCommercial · Coverage · Bone & Joints (Orthopedic) · Orthopedics, Neurosurgery, Pain Management +1 moreMedium impact

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

Effective date
Oct 15, 2026
Identified
Jul 16, 2026

Summary

Vertebral augmentation with PMMA cement under imaging guidance is medically necessary for prophylactic vertebroplasty to facilitate fusion surgery, and for malignant conditions including osteolytic metastases, destruction of a vertebral body by multiple myeloma, or primary malignant neoplasm of bone or bone marrow with daily clinically significant pain. For non-malignant conditions it is medically necessary for osteoporotic or osteolytic vertebral compression fractures, aggressive space-occupying lesions (hemangioma or eosinophilic granuloma), osteonecrotic (Kummel disease) fractures, and steroid-induced fractures when imaging matches symptoms and exam findings and the pain duration and treatment criteria are met. Vertebral augmentation is not medically necessary with listed contraindications such as allergy to materials, uncorrected coagulation disorder or anticoagulation therapy, active infection, or active osteomyelitis of the target vertebra, and percutaneous sacroplasty is investigational for all indications.

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What to do

Action · 8 steps
01Already effective 2026-10-15: Billing team should confirm that vertebral augmentation for prophylactic vertebroplasty or non-malignant conditions is performed at no more than two levels of the T5-L5 spine on the same date of service.
02For spinal surgery prior authorization requests, include the CPT codes, ICD-10 codes, and disc levels or motion segments for the planned surgery, detailed documentation of the type, duration and frequency of provider-directed non-surgical treatment with the response to each treatment, detailed documentation of less than clinically meaningful improvement for each treatment, and written reports of the most recent CT, MRI or myelography interpreted by an independent radiologist.
03Clinically significant discrepancies between the surgeon and the radiologist must be reconciled before the documentation is submitted.
04For subacute axial pain greater than six weeks, confirm the record shows less than clinically meaningful improvement after four weeks of prescription strength analgesics, steroids and/or NSAIDs and four weeks of a provider-directed exercise program.
05For osteoporotic compression fractures, confirm the individual is enrolled in an osteoporosis treatment and prevention program.
06Do not bill percutaneous vertebroplasty or mechanical vertebral augmentation separately when combined with any open spine procedure, because the policy states these will not be separately reimbursed.
07Treat percutaneous sacroplasty (CPT 0200T and 0201T) as investigational for all indications.
08Verify each code against the code section, because codes may not be covered under all circumstances.

Codes mentioned

225102251122512225132251422515C1062C7504C7505C7507C7508C41.2D18.09

Original notice

Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty - (Effective Date - 2026-10-15) 6.01.17
excellusbcbs.com · Always check the source before changing claims.
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Related changes

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Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12MediumEffective Nov 16, 2025 · Radiation TreatmentPercutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty 6.01.17HighEffective Oct 15, 2025 · Bone & Joints (Orthopedic)Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty 6.01.17HighEffective Oct 15, 2025 · Bone & Joints (Orthopedic)Browse every Excellus BlueCross BlueShield change in the policy list

Related policy hubs

Excellus BlueCross BlueShield policiesOrthopedicsNeurosurgeryPain ManagementOncologyCode 22510Code 22511Code 22512Code 22513Code 22514Code 22515Code C1062Code C7504Code C7505Code C7507Code C7508Code C41.2Code D18.09

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