Medicare (CMS LCD/NCD) Vertebroplasty/Kyphoplasty prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515), for Medicare (NJ WISeR), Medicare, Medicare (NC) plans. Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Palmetto GBA LCD L38737 - Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (revision effective 11/20/2025). "Coverage Indications, Limitations, and/or Medical Necessity" section, VERBATIM from the CMS Medicare Coverage Database API on 2026-09-20 (HTML converted to text; nothing paraphrased): PVA (percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP)) is covered in patients who qualify based on the following criteria : 1. Inclusion criteria ( ALL are required ):  Acute (<6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 – L5) by recent (within 30 days) advanced imaging (bone marrow edema on magnetic resonance imaging (MRI) or bone-scan/single photon emission computed tomography (SPECT)/computed tomography (CT) uptake) 1-3,10,25,27 Symptomatic ( ONE ): Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score ≥8) 4-7 Non-hospitalized with moderate-to-severe pain (NRS or VAS ≥5) despite optimal non-surgical management (NSM) 10 * ( ONE ): Worsening pain Stable-to-improved pain (but NRS or VAS still ≥5) ( with ≥ 2 of the following ): Progression of vertebral body height loss >25% vertebral body height reduction Kyphotic deformity Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17) *Consider including pedicle periosteal infiltration 7 c. Continuum of care 10 (BOTH) : All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and osteoporosis education for subsequent treatment as indicated. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program. 2. Exclusion criteria 2,5,8-10 : a. Absolute contraindication: Current back pain is not primarily due to the identified acute or subacute VCF(s) Osteomyelitis, discitis or active systemic or surgical site infection Pregnancy b. Relative contraindication: Allergy to bone cement or opacification agents Uncorrected coagulopathy Spinal instability Myelopathy from the fracture Neurologic deficit Neural impingement Fracture retropulsion/canal compromise Greater than 3 vertebral fractures Vertebral augmentation and kyphoplasty for VCFs with intractable spinal pain not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving a vertebral body. [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 Medicare (CMS LCD/NCD) policy.
How to submit
- Method: Traditional Medicare: no prior authorization in the office or ASC setting - bill Part B with documentation on file. If performed in a HOSPITAL OUTPATIENT DEPARTMENT, check the CMS OPD prior-authorization list for the specific code before the date of service. Medicare Advantage plans (Humana, UHC, Aetna, Blue Medicare) require their own PA but must apply this LCD's criteria under 42 CFR 422.101(b).
Sources & verification
- BindingSource - LCD: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38737) · 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 2026-09-20.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Vertebroplasty/Kyphoplasty?
Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
What does Medicare (CMS LCD/NCD) require to approve Vertebroplasty/Kyphoplasty?
Palmetto GBA LCD L38737 - Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (revision effective 11/20/2025). "Coverage Indications, Limitations, and/or Medical Necessity" section, VERBATIM from the CMS Medicare Coverage Database API on 2026-09-20 (HTML converted to text; nothing paraphrased): PVA (percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP)… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Vertebroplasty/Kyphoplasty to Medicare (CMS LCD/NCD)?
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.