QualCare Vertebroplasty/Kyphoplasty prior authorization requirements (2026)
What QualCare generally requires to approve Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515), for commercial plans. Yes. QualCare generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
Medical-necessity criteria QualCare generally applies
Prior authorization via eviCore (Cigna CMM-607). Osteoporotic/osteolytic/osteonecrotic/steroid-induced VCF or malignant lesion; at most 2 levels T5-L5 per date of service; imaging concordant with symptoms; clinically significant functional impairment; EITHER acute (0-6 weeks) axial pain preventing independent transfers/ambulation OR subacute (over 6 weeks) axial pain after at least 4 weeks analgesics/steroids/NSAIDs AND at least 4 weeks provider-directed exercise; osteoporosis-program enrollment required (malignant/pathologic fractures exempt from non-surgical management).
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 QualCare policy.
How to submit
- Method: eviCore portal
- Portal: eviCore by Evernorth (Cigna MSK/Spine)
Sources & verification
- BindingSource — Cigna CMM-607 Primary Vertebral Augmentation and Sacroplasty (CMM-607) · effective 2024-11-01.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 QualCare require prior authorization for Vertebroplasty/Kyphoplasty?
Yes. QualCare generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
What does QualCare require to approve Vertebroplasty/Kyphoplasty?
Prior authorization via eviCore (Cigna CMM-607). Osteoporotic/osteolytic/osteonecrotic/steroid-induced VCF or malignant lesion; at most 2 levels T5-L5 per date of service; imaging concordant with symptoms; clinically significant functional impairment; EITHER acute (0-6 weeks) axial pain preventing independent transfers/ambulation OR subacute (over 6 weeks) axial pain after at least 4 weeks analges… Always confirm against the current QualCare policy.
How long does a QualCare prior authorization take?
Turnaround varies by plan and submission method. Check the QualCare portal for current timeframes.
Submitting Vertebroplasty/Kyphoplasty to QualCare?
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.