eviCore Vertebroplasty/Kyphoplasty prior authorization requirements (2026)
What eviCore generally requires to approve Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515), for Commercial plans. Yes. eviCore generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
Medical-necessity criteria eviCore generally applies
Patient must meet ALL: (1) Acute or subacute vertebral compression fracture — fracture age ≤6 months (MRI STIR sequence showing acute edema preferred to confirm acuity); (2) Osteoporotic fracture confirmed by DEXA scan (T-score ≤ -2.5) OR fragility fracture mechanism; (3) Significant pain and functional limitation attributable to fracture; (4) Failure of conservative pain management ≥3–4 weeks (bed rest, analgesics, bracing) UNLESS functional status severely compromised; (5) No neurological compromise requiring decompressive surgery; (6) No pathological fracture from malignancy (requires oncology clearance)
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 eviCore policy.
Commonly required documentation
- MRI spine with STIR sequence confirming acute marrow edema at fracture level
- DEXA scan results
- X-rays or CT confirming fracture morphology
- pain score documentation
- conservative treatment records
- oncology records if pathological fracture suspected or known malignancy
How to submit
- Portal: eviCore Connect
- Typical turnaround: about 2 days
Source
MRI STIR sequence is critical — eviCore uses acuity of fracture (active marrow edema) as key criterion. Chronic fractures without edema on STIR are routinely denied. Pathological fractures from malignancy require oncology documentation.
Frequently asked questions
Does eviCore require prior authorization for Vertebroplasty/Kyphoplasty?
Yes. eviCore generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
What does eviCore require to approve Vertebroplasty/Kyphoplasty?
Patient must meet ALL: (1) Acute or subacute vertebral compression fracture — fracture age ≤6 months (MRI STIR sequence showing acute edema preferred to confirm acuity); (2) Osteoporotic fracture confirmed by DEXA scan (T-score ≤ -2.5) OR fragility fracture mechanism; (3) Significant pain and functional limitation attributable to fracture; (4) Failure of conservative pain management ≥3–4 weeks (be… Always confirm against the current eviCore policy.
How long does a eviCore prior authorization take?
eviCore typically decides Vertebroplasty/Kyphoplasty requests in about 2 days. Timeframes vary; check the payer portal.
Submitting Vertebroplasty/Kyphoplasty to eviCore?
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.