AIM (out-of-state / Federal BCBS) Vertebroplasty/Kyphoplasty prior authorization requirements (2026)
What AIM (out-of-state / Federal BCBS) generally requires to approve Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515), for commercial plans. Yes. AIM (out-of-state / Federal BCBS) generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
Medical-necessity criteria AIM (out-of-state / Federal BCBS) generally applies
Prior authorization via Carelon (Spine Surgery MSK03-1125.1, Vertebroplasty/Kyphoplasty section). For osteoporosis/osteopenia VCF, ALL required: recent onset of back pain localized to the fracture site that has not responded to at least 6 weeks of conservative medical management (bed rest/activity, analgesics, PT, bracing, calcitonin, bisphosphonates, calcium); tenderness to palpation directly over the fracture site; advanced imaging confirming a non-traumatic acute compression fracture; recent MRI or CT excluding disc herniation or other causes; and absence of cord-risk findings (stenosis over 20% from retropulsed fragments, collapse under one-third height, vertebra plana over 90%, burst fracture). Separate indications for metastasis/myeloma and hemangioma.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Vertebroplasty/Kyphoplasty. Confirm the covered diagnosis list against the current AIM (out-of-state / Federal BCBS) policy.
How to submit
- Method: Carelon ProviderPortal
- Portal: Carelon Medical Benefits Management
Sources & verification
- BindingSource — Carelon Clinical Appropriateness Guidelines — Spine Surgery (Vertebroplasty/Kyphoplasty) (MSK03-1125.1-UC0126) · effective 2026-01-01.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-06-26.
Frequently asked questions
Does AIM (out-of-state / Federal BCBS) require prior authorization for Vertebroplasty/Kyphoplasty?
Yes. AIM (out-of-state / Federal BCBS) generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
What does AIM (out-of-state / Federal BCBS) require to approve Vertebroplasty/Kyphoplasty?
Prior authorization via Carelon (Spine Surgery MSK03-1125.1, Vertebroplasty/Kyphoplasty section). For osteoporosis/osteopenia VCF, ALL required: recent onset of back pain localized to the fracture site that has not responded to at least 6 weeks of conservative medical management (bed rest/activity, analgesics, PT, bracing, calcitonin, bisphosphonates, calcium); tenderness to palpation directly ove… Always confirm against the current AIM (out-of-state / Federal BCBS) policy.
How long does a AIM (out-of-state / Federal BCBS) prior authorization take?
Turnaround varies by plan and submission method. Check the AIM (out-of-state / Federal BCBS) portal for current timeframes.
Submitting Vertebroplasty/Kyphoplasty to AIM (out-of-state / Federal BCBS)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.