Anthem Blue Cross Blue Shield / Elevance (Commercial) · percutaneous vertebral augmentation

.KYPHOANTHEM

Assessment: *** — painful vertebral compression fracture or lesion at ***, one of:
[osteoporotic/osteopenic VCF] with recent-onset pain, point tenderness over the fracture
site, advanced imaging confirming a NON-TRAUMATIC ACUTE compression fracture, and a recent
MRI/CT excluding another cause | [osteolytic metastasis / myeloma / plasmacytoma] with severe
pain and a lesion not involving a major part of cortical bone | [aggressive vertebral
hemangioma] with severe pain or nerve compression after radiation failure | [eosinophilic
granuloma] with pain and spinal instability.

Medical necessity per Carelon MSK03 (Spine Surgery), vertebral augmentation: on the VCF
pathway, conservative management has failed over >=6 weeks or was contraindicated — bed rest
progressing to activity, analgesics, physical therapy, bracing, and calcitonin /
bisphosphonates / calcium: *** ; the tumor, hemangioma, and EG pathways carry no conservative
floor. Every safety criterion holds: spinal stenosis <=20% from retropulsion, vertebral
collapse not below 33% residual height, not vertebra plana (>90% collapse), no burst fracture
with retropulsed fragments, and safe needle access. The exclusions are absent: this is not a
high-energy traumatic VCF, the fracture is not >1 year old, it is not asymptomatic, this is
not prophylaxis (neither without an acute fracture nor for proximal junctional kyphosis after
fusion), and this is not sacroplasty.

Plan: Percutaneous *** (kyphoplasty 22513 thoracic / 22514 lumbar [+22515 each add'l]; or
vertebroplasty 22510-22512) at level(s) ***, under imaging guidance. Risks, benefits, and
alternatives discussed; consent obtained.