Clover Health Vertebroplasty/Kyphoplasty prior authorization requirements (2026)
What Clover Health generally requires to approve Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515), for medicare_advantage plans. Yes. Clover Health generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
Medical-necessity criteria Clover Health generally applies
Prior authorization required via eviCore. There is NO Medicare NCD for vertebral augmentation — coverage is governed by the MAC LCD. Per NGS LCD L33569 (Percutaneous Vertebral Augmentation): acute (under 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1-L5) by symptom onset, confirmed by advanced imaging (bone-marrow edema on MRI OR bone-scan/SPECT/CT uptake), AND symptomatic by either hospitalized with NRS/VAS at least 8, or non-hospitalized NRS/VAS at least 5 despite optimal non-surgical management.
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 Clover Health policy.
How to submit
- Method: eviCore portal
- Portal: eviCore (by Evernorth)
Sources & verification
- BindingSource — LCD L33569 — Percutaneous Vertebral Augmentation for Vertebral Compression Fracture (no NCD exists) (L33569) · effective 2025-11-20.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 Clover Health require prior authorization for Vertebroplasty/Kyphoplasty?
Yes. Clover Health generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
What does Clover Health require to approve Vertebroplasty/Kyphoplasty?
Prior authorization required via eviCore. There is NO Medicare NCD for vertebral augmentation — coverage is governed by the MAC LCD. Per NGS LCD L33569 (Percutaneous Vertebral Augmentation): acute (under 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1-L5) by symptom onset, confirmed by advanced imaging (bone-marrow edema on MRI OR bone-scan/SPECT/CT uptake), AND symptomatic by either hospit… Always confirm against the current Clover Health policy.
How long does a Clover Health prior authorization take?
Turnaround varies by plan and submission method. Check the Clover Health portal for current timeframes.
Submitting Vertebroplasty/Kyphoplasty to Clover Health?
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.