UnitedHealthcare Vertebroplasty/Kyphoplasty prior authorization requirements (2026)
What UnitedHealthcare generally requires to approve Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515), for PPO plans. Yes. UnitedHealthcare generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
Medical-necessity criteria UnitedHealthcare generally applies
Prior authorization required (all states). Per UnitedHealthcare Commercial Medical Policy "Percutaneous Vertebroplasty and Kyphoplasty" (2026T0581Q, eff 3/1/2026), vertebroplasty and kyphoplasty are proven and medically necessary for pain causing functional or physical impairment in cervical, thoracic, or lumbar vertebral bodies WITHIN 4 MONTHS of pain onset that has failed to respond to Optimal Medical Therapy, for: osteoporotic vertebral compression fracture (VCF); steroid-induced vertebral fracture; osteolytic metastatic disease involving a vertebral body; multiple myeloma involving a vertebral body; vertebral hemangioma with aggressive features; or unstable fractures due to osteonecrosis (e.g., Kummel disease). CT or MRI must have ruled out other causes of spinal pain (foraminal stenosis, herniated disc, other generators), and none of the following may be present: clinical evidence of spinal cord compression; significant vertebral collapse/destruction (vertebra reduced to less than one-third of its original height); a healed VCF; an asymptomatic VCF; or a VCF responding appropriately to conservative therapy.
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 UnitedHealthcare policy.
Related procedure codes
Codes often billed alongside Vertebroplasty/Kyphoplasty: 22510, 22511, 22512, 22513, 22514, 22515. Verify the correct codes for your documentation.
Commonly required documentation
- CT or MRI ruling out other spinal pain generators
- documentation of the qualifying indication
- onset of the condition (dates/duration) within 4 months
- failure of Optimal Medical Therapy
- symptoms, pain location/severity, and functional impairment.
Situations to verify before submitting
UnitedHealthcare may not cover Vertebroplasty/Kyphoplasty in these situations. Verify against the current policy rather than assuming a denial:
- Indications other than the listed osteoporotic/steroid-induced/osteolytic-mets/myeloma/aggressive-hemangioma/osteonecrosis fractures - unproven and not medically necessary
- Clinical evidence of spinal cord compression
- Significant vertebral collapse or destruction (vertebra reduced to less than one-third of original height)
- Healed VCF
- Asymptomatic VCFs, or VCFs responding appropriately to conservative therapy
- Sacral or coccyx lesions (covered under the Minimally Invasive Spine Surgery policy)
How to submit
- Method: portal
- Portal: UnitedHealthcare Provider Portal
Sources & verification
- BindingPayer medical policy — UHC Commercial Medical Policy - Percutaneous Vertebroplasty and Kyphoplasty (2026T0581Q) · effective 2026-03-01.View
- BindingPayer medical policy — UHC Commercial Advance Notification / Prior Authorization Requirements.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 2026-06-20.
Frequently asked questions
Does UnitedHealthcare require prior authorization for Vertebroplasty/Kyphoplasty?
Yes. UnitedHealthcare generally requires prior authorization for Vertebroplasty/Kyphoplasty (CPT 22510, 22511, 22512, 22513, 22514, 22515).
What does UnitedHealthcare require to approve Vertebroplasty/Kyphoplasty?
Prior authorization required (all states). Per UnitedHealthcare Commercial Medical Policy "Percutaneous Vertebroplasty and Kyphoplasty" (2026T0581Q, eff 3/1/2026), vertebroplasty and kyphoplasty are proven and medically necessary for pain causing functional or physical impairment in cervical, thoracic, or lumbar vertebral bodies WITHIN 4 MONTHS of pain onset that has failed to respond to Optimal M… Always confirm against the current UnitedHealthcare policy.
How long does a UnitedHealthcare prior authorization take?
Turnaround varies by plan and submission method. Check the UnitedHealthcare portal for current timeframes.
Submitting Vertebroplasty/Kyphoplasty to UnitedHealthcare?
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.