Blue Cross NC Vertebroplasty/Kyphoplasty prior authorization requirements (2026)

Medical-necessity criteria Blue Cross NC generally applies

Percutaneous Vertebroplasty or Kyphoplasty - "is considered medically necessary for treatment of the following conditions: Osteolytic vertebral metastasis, myeloma, or plasmacytoma with severe back pain related to destruction of the vertebral body NOT involving the major part of the cortical bone; Vertebral hemangiomas with severe pain or nerve compression, or aggressive radiologic signs, when radiation therapy has failed to relieve symptoms; Eosinophilic granuloma with pain and spinal instability; Vertebral compression fracture due to osteoporosis or osteopenia when ALL the following requirements are met: Recent onset of back pain localized to the fracture site which has not responded to at least 6 weeks of conservative medical management (Conservative management should include, but is not limited to, initial bed rest with progressive activity, analgesics, physical therapy, bracing and exercises to correct postural deformity and increase muscle tone, salmon calcitonin, bisphosphonates, and calcium supplementation); Tenderness to palpation directly over the fracture site; Advanced imaging studies confirming a non-traumatic, acute compression fracture; Recent imaging studies (MRI or CT) which eliminate disc herniation or other causes of spine pain; Absence of imaging findings which would confer unacceptable risk to the spinal cord or related structures, including ALL the following: Spinal stenosis of greater than 20% due to retropulsed fragments; Vertebral body collapse to less than one third (33%) original height; Vertebral plana (collapse greater than 90%); Anatomical damage of the vertebra that prevents safe access of the needle to the vertebral body; Burst fracture with retropulsed fragments demonstrated by imaging." [NEEDS CLINICAL SPOT-CHECK]

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 Blue Cross NC policy.

Commonly required documentation

• Dated record of at least 6 weeks of conservative management (activity progression, analgesics, PT, bracing, calcitonin/bisphosphonate/calcium where used)
• exam documenting tenderness over the fracture
• MRI or CT confirming an acute non-traumatic compression fracture and excluding other pain sources
• imaging measurements of retropulsion, height loss and canal compromise.

Situations to verify before submitting

Blue Cross NC may not cover Vertebroplasty/Kyphoplasty in these situations. Verify against the current policy rather than assuming a denial:

• {"text":"Contraindications: \"Severe cardiopulmonary disease; Coagulation disorders; Known allergy to any of the materials used in either procedure; Active or incompletely treated infection.\" Exclusions: \"Prophylaxis in patients deemed to be at risk but with no evidence of acute vertebral fracture; Prophylaxis for the prevention of proximal junctional kyphosis and failure following posterior spinal fusion; Non-pathologic, acute (high-energy) traumatic fractures of the vertebra; Compression fractures shown by the medical record to be more than one year old; Asymptomatic vertebral compression fracture. Percutaneous sacroplasty is considered not medically necessary for all indications.\"","source":"https://guidelines.carelonmedicalbenefitsmanagement.com/spine-surgery-2026-09-19/"}

How to submit

• Method: Prior authorization is delegated to Carelon Medical Benefits Management for spine surgery, joint surgery, interventional pain management, and small joint surgery (Commercial Fully Insured since 2023-10-01; ASO groups only if the group elected the program, effective 2025-01-01 - verify by member ID on the Carelon portal or via the number on the member ID card). Submit through the Carelon Provider Portal via Blue e (24/7, real-time against Carelon clinical guidelines) or by phone at 866-455-8414, Monday-Friday 8 a.m.-6 p.m. ET. Applies in both outpatient and inpatient admission settings. Since 2025-07-01 (Fully Insured only; excludes Medicare Advantage, DSNP, EGWP, FEP and ASO), a request for a hospital-based OUTPATIENT setting for interventional pain or joint-arthroscopy/small-joint procedures gets an additional site-of-care review.
• Portal: Carelon Provider Portal (via Blue e)
• Typical turnaround: about 3 days

Sources & verification

• BindingSource - Carelon Clinical Appropriateness Guidelines: Spine Surgery (Spine Surgery 2026-09-19) · effective 2026-09-19.View
• BindingSource - Blue Cross NC Musculoskeletal Program and Interventional Pain Management effective October 1, 2023 (Carelon delegation) (Provider news 2023-10-01) · effective 2023-10-01.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 2026-09-20.

Frequently asked questions

Other Blue Cross NC prior authorization requirements

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