Oscar Health Vertebroplasty/Kyphoplasty prior authorization requirements (2026)
What Oscar Health generally requires to approve Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515), for commercial plans. Yes. Oscar Health generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
Medical-necessity criteria Oscar Health generally applies
Prior authorization required via eviCore (CMM-607 Primary Vertebral Augmentation). Medically necessary for osteoporotic/osteolytic/osteonecrotic/steroid-induced VCF (or malignant lesion), at most 2 levels of T5-L5 per date of service, imaging concordant with symptoms, plus EITHER acute (0-6 weeks) axial pain preventing independent transfers/ambulation OR subacute (over 6 weeks) axial pain with less than clinically meaningful improvement after BOTH at least 4 weeks prescription analgesics/steroids/NSAIDs AND at least 4 weeks provider-directed exercise; osteoporotic patients must be enrolled in an osteoporosis program.
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 Oscar Health policy.
How to submit
- Method: eviCore portal
- Portal: eviCore (by Evernorth)
Sources & verification
- BindingSource — eviCore CMM-607 Primary Vertebral Augmentation and Sacroplasty (CMM-607) · effective 2025-07-01.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 Oscar Health require prior authorization for Vertebroplasty/Kyphoplasty?
Yes. Oscar Health generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
What does Oscar Health require to approve Vertebroplasty/Kyphoplasty?
Prior authorization required via eviCore (CMM-607 Primary Vertebral Augmentation). Medically necessary for osteoporotic/osteolytic/osteonecrotic/steroid-induced VCF (or malignant lesion), at most 2 levels of T5-L5 per date of service, imaging concordant with symptoms, plus EITHER acute (0-6 weeks) axial pain preventing independent transfers/ambulation OR subacute (over 6 weeks) axial pain with les… Always confirm against the current Oscar Health policy.
How long does a Oscar Health prior authorization take?
Turnaround varies by plan and submission method. Check the Oscar Health portal for current timeframes.
Submitting Vertebroplasty/Kyphoplasty to Oscar 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.