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Regence BlueShieldAll Plans · Coverage · Medical Policy · Orthopedics, Neurosurgery, Radiology +1 moreMedium impact

Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

Effective date
Oct 1, 2026
Identified
Oct 7, 2026

Summary

Mechanical vertebral augmentation with SpineJack or Kiva, percutaneous vertebroplasty, or balloon kyphoplasty may be considered medically necessary in select patients with vertebral fractures when the policy criteria are met. Coverage applies to no more than three symptomatic vertebral fractures of the T5-L5 spine on any single date of service, and to symptomatic osteoporotic vertebral fractures less than six weeks in duration that have led to hospitalization or persist at a level that prevents ambulation or transfers without assistance. Sacroplasty, coccygeoplasty, augmentation of the cervical spine or T1-5, and mechanical augmentation using any device other than a balloon, such as radiofrequency-assisted augmentation or vertebral body stenting, are considered investigational.

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What to do

Action · 8 steps
01Already effective October 1, 2026: For a vertebral augmentation request under the first criterion, no more than three symptomatic fractures of the T5-L5 spine may be treated on one date of service.
02The record must include preoperative imaging (plain film x-ray, MRI, CT, or bone scan) that correlates with the patient's pain, and documentation that the pain is more likely than not related to the demonstrated fracture.
03The record must specifically document each instrumental activity of daily living that is impaired and a description of how performance is limited.
04The record must also document at least six weeks of conservative nonoperative therapy that failed, including at least two of the following: analgesics or NSAIDs if not contraindicated, a trial of physical therapy, or alteration of activities.
05A pre-procedure assessment must document the absence of the listed contraindications, including untreated symptomatic foraminal or canal stenosis, facet arthropathy or other significant pain generators at the planned level, bone fragment retropulsion, unstable fracture or need for stabilization in the same or adjacent region, active infection, uncorrected coagulation disorders, and known allergy to the materials used.
06For osteoporotic fractures under the second criterion, the fracture must be less than six weeks in duration and must have led to hospitalization or persist at a level that prevents ambulation or transfers without assistance.
07Required documentation includes history and physical or chart notes, current symptomology, imaging results, a description of functional impairment and how it limits instrumental ADLs, conservative treatments attempted for at least six weeks with documented response, and the pre-procedure assessment.
08If any of these items is not submitted, it could impact the review and decision outcome.

Codes mentioned

225102251122512225132251422515C1062C7504C7505C7507C7508

Original notice

Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty
beonbrand.getbynder.com · Always check the source before changing claims.
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Related changes

See all Regence BlueShield changes →
Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and CoccygeoplastyHighEffective Oct 1, 2026 · Medical PolicyBrowse every Regence BlueShield change in the policy list

Related policy hubs

Regence BlueShield policiesOrthopedicsNeurosurgeryRadiologyPain ManagementCode 22510Code 22511Code 22512Code 22513Code 22514Code 22515Code C1062Code C7504Code C7505Code C7507Code C7508

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