Horizon BCBS NJ Vertebroplasty/Kyphoplasty prior authorization requirements (2026)
What Horizon BCBS NJ generally requires to approve Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515), for PPO plans. Yes. Horizon BCBS NJ generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
Medical-necessity criteria Horizon BCBS NJ generally applies
Prior authorization required; managed by TurningPoint Healthcare Solutions under the Horizon Surgical & Implantable Device Management Program (spine services, policy OR-1024, Kyphoplasty and Vertebroplasty; Horizon moved spine PA/MND from eviCore to TurningPoint). Binding OR-1024 text is portal-only; the medical-necessity standard below reflects the evidence-based Carelon Spine Surgery guideline (MSK03-1125.1, eff. 11/15/2025) vertebral-augmentation section. Indicated for an acute/subacute painful osteoporotic OR malignant vertebral compression fracture with: recent onset of pain correlating to the level of fracture; MRI or CT demonstrating acute marrow edema at the level to be treated; and failure of conservative management (the Carelon standard specifies a short trial, reported as at least ~2 weeks). Verify binding criteria, the exact conservative-care duration, and the impacted-code set in the TurningPoint portal / Horizon Prior Authorization Procedure Search for the member''s plan.
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 Horizon BCBS NJ policy.
Related procedure codes
Codes often billed alongside Vertebroplasty/Kyphoplasty: 22510, 22511, 22512, 22513, 22514, 22515. Verify the correct codes for your documentation.
Situations to verify before submitting
Horizon BCBS NJ may not cover Vertebroplasty/Kyphoplasty in these situations. Verify against the current policy rather than assuming a denial:
- Asymptomatic vertebral compression fracture
- Chronic healed fracture without acute marrow edema
- Fracture with epidural involvement causing cord compression or significant retropulsion
- Coagulopathy that cannot be corrected
- Active infection at the injection or surgical site
How to submit
- Method: portal
- Portal: TurningPoint Healthcare Solutions Web Portal
Source
Spine PA at Horizon moved eviCore -> TurningPoint (NJ DOBI-approved); vertebral augmentation mapped to TurningPoint policy OR-1024 (Kyphoplasty and Vertebroplasty), confirmed via the public TurningPoint coding-to-policy crosswalk (same program). Criteria framed from the public Carelon Spine Surgery guideline MSK03-1125.1 (eff 11/15/2025, ) as the evidence-based standard; binding OR-1024 text is portal-only (myturningpoint-healthcare.com). The ~2-week conservative-care duration is the Carelon page value and is [NEEDS VERIFICATION] against the source PDF; society policy (ISASS 2018) no longer mandates a waiting period, so payer criteria are more conservative. Sacroplasty is coded 0200T/0201T (not in this row''s 22510-22515 set) but sits in the same OR-1024 group. A separate Horizon medical-necessity claim edit for 22510-22515 applies to DOS on/after 01/18/2018. PA applicability varies by group funding; verify per member. [SPOT-CHECK] View the source policy. Last verified 2026-06-18.
Frequently asked questions
Does Horizon BCBS NJ require prior authorization for Vertebroplasty/Kyphoplasty?
Yes. Horizon BCBS NJ generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
What does Horizon BCBS NJ require to approve Vertebroplasty/Kyphoplasty?
Prior authorization required; managed by TurningPoint Healthcare Solutions under the Horizon Surgical & Implantable Device Management Program (spine services, policy OR-1024, Kyphoplasty and Vertebroplasty; Horizon moved spine PA/MND from eviCore to TurningPoint). Binding OR-1024 text is portal-only; the medical-necessity standard below reflects the evidence-based Carelon Spine Surgery guideline (… Always confirm against the current Horizon BCBS NJ policy.
How long does a Horizon BCBS NJ prior authorization take?
Turnaround varies by plan and submission method. Check the Horizon BCBS NJ portal for current timeframes.
Submitting Vertebroplasty/Kyphoplasty to Horizon BCBS NJ?
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.