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 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
No nationwide Part B prior authorization. EXCEPTION - WISeR model (from Jan 2026, NJ/OH/OK/TX/AZ/WA): percutaneous vertebral augmentation (vertebroplasty/kyphoplasty) is a WISeR service category - in those states submit prior authorization or the claim faces 100% pre-payment medical review. Not on the hospital-OPD PA list. Medical-necessity documentation per the applicable MAC LCD. [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.
Commonly required documentation
- Clinical documentation per the applicable NCD/LCD: diagnosis, conservative-care history, imaging correlation, and (for repeat procedures) documented response.
How to submit
- Method: Office/professional claims: no PA to submit outside WISeR states. HOPD claims for OPD-list services: hospital submits PA to the MAC.
Sources & verification
Sources: CMS WISeR model page (cms.gov/priorities/innovation/innovation-models/wiser, verified 2026-07-09); CMS hospital-OPD prior-authorization program (42 CFR 419.83); KFF WISeR analysis (kff.org). WISeR states: NJ, OH, OK, TX, AZ, WA; six-year model from Jan 1, 2026. Last verified 2026-07-09.
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?
No nationwide Part B prior authorization. EXCEPTION - WISeR model (from Jan 2026, NJ/OH/OK/TX/AZ/WA): percutaneous vertebral augmentation (vertebroplasty/kyphoplasty) is a WISeR service category - in those states submit prior authorization or the claim faces 100% pre-payment medical review. Not on the hospital-OPD PA list. Medical-necessity documentation per the applicable MAC LCD. [NEEDS CLINICAL… 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.