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Cigna Healthcare (Commercial) · percutaneous vertebral augmentation

v1verified 2026-07-24manual-pull source

✓ conditional · commercial

Criteria checklist

0 of 6 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Painful vertebral compression fracture / lesion (T5-L5), imaging-concordant
      • criteria:
        • levels: T5-L5 only; <=2 levels per date of service
        • etiologies:
          • osteoporotic
          • osteolytic
          • osteonecrotic (Kummell)
          • steroid-induced
          • aggressive hemangioma / eosinophilic granuloma
          • malignancy (osteolytic mets, myeloma, primary bone/marrow tumor)
          • prophylactic to facilitate fusion
        • imaging: concordant with symptoms/exam; functional impairment documented
  • conservative pathway:
    • acute: 0-6 weeks, pain preventing transfers/ambulation -> no conservative trial required
    • subacute: >6 weeks -> requires 4 weeks Rx analgesics/NSAIDs AND 4 weeks provider-directed exercise
    • osteoporotic fx: must be enrolled in an osteoporosis treatment/prevention program
    • urgent emergent: pathologic fracture / incapacitating pain bypasses non-surgical management
  • investigational:
    • percutaneous SACROPLASTY and coccygeoplasty
    • cervical and T1-T4 levels
    • prophylaxis for osteoporosis or chronic LBP (>6 months, even with an old fracture)
    • non-painful hemangioma; spinoplasty / OptiMesh; non-FDA-approved cement
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • min duration weeks: 4
  • satisfied by:
    • acute (0-6 wk) disabling: none required
    • subacute (>6 wk): 4 wk meds + 4 wk exercise
    • urgent/emergent: bypass
    • contraindicated
  • modalities named:
    • analgesics / NSAIDs / steroids
    • provider-directed exercise
    • osteoporosis program (osteoporotic fx)
Trial
  • required: no
  • min duration days: not stated in the policy
  • success criteria: not stated in the policy
  • threshold is binding: no
Psychological evaluation
  • required: no
  • must clear: no
  • note posture: not required
Quantity limits
  • applies: yes
  • levels per dos: 2
  • eligible levels: T5-L5
Payor-specific notes

Cigna delegates vertebral augmentation to eviCore CMM-607. Covers painful VCF/lesion at T5-L5 (<=2 levels/DOS) with concordant imaging. Conservative pathway is acuity-tiered: acute (0-6 wk) disabling pain needs no trial; subacute (>6 wk) requires 4 weeks meds + 4 weeks exercise; osteoporotic fractures must be enrolled in an osteoporosis program. KEY divergences from Medicare: hard T5-L5 + <=2-level caps; osteoporosis-program enrollment; flatly excludes SACROPLASTY, coccygeoplasty, and cervical/T1-T4; does NOT mandate MR marrow edema. From the actual fetched eviCore PDF (criteria unchanged from V1.0.2024).

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Dot phrase

Self-contained narrative A&P attestation. `***` = fill-in. Maps to eviCore CMM-607 (Primary Vertebral Augmentation), UM delegated by Cigna. Hard caps: T5-L5 only, <=2 levels per date of service; the conservative requirement is ACUITY-TIERED — date the pain onset in the note.

.KYPHOCIGNA
.KYPHOCIGNA

Assessment: *** — painful vertebral compression fracture or lesion at *** (T5-L5 only, <=2
levels this DOS), with imaging concordant with the symptoms and examination and functional
impairment documented. Etiology: *** (osteoporotic / osteolytic / osteonecrotic [Kummell] /
steroid-induced / aggressive hemangioma or eosinophilic granuloma / malignancy [osteolytic
mets, myeloma, primary bone-marrow tumor] / prophylactic to facilitate fusion).

Medical necessity per Cigna eviCore CMM-607: the conservative requirement is acuity-tiered,
and this patient falls in the [acute, 0-6 wk] tier with pain preventing transfers and
ambulation, which requires no conservative trial | the [subacute, >6 wk] tier, having
completed 4 weeks of prescription analgesics/NSAIDs and 4 weeks of provider-directed
exercise: *** | the [urgent/emergent] tier with a pathologic fracture or incapacitating pain,
which bypasses non-surgical management — or conservative care was contraindicated. [If the
fracture is osteoporotic:] the patient is enrolled in an osteoporosis treatment and
prevention program: *** . The exclusions are absent: this is not sacroplasty or
coccygeoplasty, not cervical or T1-T4, not prophylaxis for osteoporosis or chronic low back
pain (>6 months, even with an old fracture), and not a non-painful hemangioma; no spinoplasty
or OptiMesh is planned, and no non-FDA-approved cement will be used.

Plan: Percutaneous *** (kyphoplasty 22513 thoracic / 22514 lumbar [+22515 each add'l]; or
vertebroplasty 22510-22512) at level(s) *** within T5-L5 and <=2 this DOS, under imaging
guidance. Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (T5-L5 only, <=2 levels/DOS, enumerated etiologies)
  • conservative-care line (acuity-tiered: acute bypass / subacute 4 wk + 4 wk)
  • osteoporosis-program line (enrollment for osteoporotic fx)
  • exclusions (sacroplasty/coccygeoplasty, cervical & T1-T4)

Cautions

  • eviCore/Evernorth prior auth (CMM-600.1 pathway). No MR-edema mandate — imaging need only be concordant with symptoms/exam. Regenerate if `cigna-commercial-kyphoplasty.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes
  • pathway: eviCore / Evernorth (CMM-600.1)

Provenance

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Change history

  • 2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
  • 2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
  • 2026-06-28Add commercial Vertebral Augmentation cells: Anthem, UHC, Cigna ee451f0955