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You asked about Kyphoplasty / vertebral augmentation. HumanaChoice (Medicare Advantage, PPO) is governed by a framework cell — read the per-procedure line inside it and the embedded Traditional-Medicare criteria below.

HumanaChoice (Medicare Advantage, PPO) · all interventional pain

v1verified 2026-07-24needs re-verificationmanual-pull source

✓ conditional · medicare advantage

Criteria checklist

0 of 1 ticked
Indications
  • enumerated: no
  • description: HumanaChoice (PPO MA) applies the Traditional Medicare coverage FLOOR. NCD/LCD procedures use the corresponding `medicare-in-ky-*` criteria + Humana MA PA (cannot be more restrictive). For R&N procedures (Intracept, ReActiv8, endoscopic), the plan may apply its own internal criteria — pull the policy. PPO: out-of-network allowed at higher cost-share; same medical-necessity floor.
Payor-specific notes

POINTER cell. Same model as Humana Gold Plus but the PPO product (HumanaChoice) — Gold ≠ Choice (HMO vs PPO; the medical-necessity floor is identical, network/cost-share differ). Criteria = the Traditional Medicare cell per procedure + Humana MA PA; internal criteria only for R&N procedures. Plan PA vendor/process not independently verified (needs_reverification).

Ticks are a documentation aid — nothing is stored; they reset on reload.

Prior-auth pathway

  • required: yes
  • pathway: Humana MA prior authorization (MSK/spine often Cohere Health — confirm)

Provenance

  • authority:
    • type: medicare_advantage
    • floor: Traditional Medicare NCD/LCD per procedure — see policies/<procedure>/medicare-in-ky-*.md
    • plan um: Humana MA prior authorization / utilization management (MSK/spine PA often via Cohere Health — confirm)
    • applies because: Per CMS-4201-F (2024) / 42 CFR 422.101, MA must follow Traditional Medicare coverage criteria where an NCD/LCD fully establishes them; plan internal criteria only where Medicare is silent (R&N procedures)
  • source: https://www.ecfr.gov/current/title-42/section-422.101
  • effective: 2024-01-01 · payor last reviewed: — · we verified: 2026-07-24 · v1

Report an issue with this cell

Change history

  • 2026-07-24framework cells (MA x3, Medicaid IN/KY, VA): re-reviewed regulatory basis 2026-07-24 (42 CFR 422.101/CMS-4201-F, 405 IAC Art.5, KY KAR 907:3:130, 38 CFR 17.38(b) all current); plan/state-specific operational details (MA PA vendor, Medicaid interactive fee-schedule PA flags + MCO scopes, VA gated SEOC catalog/Optum manual/image-only CPG) remain gated -> needs_reverification kept; last_verified 2026-07-24 86bd4bd0b9
  • 2026-06-29Add Medicare Advantage pointer cells (Aetna, Humana Gold HMO, HumanaChoice PPO) 86a5e15292

Embedded cell · Traditional Medicare baseline

Medicare (Traditional Part A & B) — percutaneous vertebral augmentation

v2verified 2026-07-24

✓ conditional · medicare lcd

Criteria checklist

0 of 9 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Osteoporotic VCF — acute/subacute, symptomatic (both states; ALL criteria required)
      • criteria:
        • fracture levels: T1-L5
        • acuity: acute (<6 weeks) or subacute (6-12 weeks) by symptom onset
        • imaging evidence: RECENT (within 30 days) advanced imaging — bone-marrow edema on MRI OR bone-scan/SPECT/CT uptake at the level
        • symptomatic gate: ONE of: (a) HOSPITALIZED with severe pain (NRS/VAS >=8); OR (b) non-hospitalized with moderate-to-severe pain (NRS/VAS >=5) despite optimal non-surgical management AND either worsening pain OR stable-to-improved pain (still >=5) with >=2 qualifying factors: progression of vertebral height loss; >25% height reduction; kyphotic deformity; severe functional impact (RDQ >17); [WPS/IN adds factors 5-6:] steroid-induced fracture; reinforcement/stabilization of the vertebral body prior to surgery
        • continuum of care: BOTH required: referral for bone-mineral-density evaluation + osteoporosis education, AND instruction to take part in an osteoporosis prevention/treatment program
      • name: Malignant VCF — osteolytic metastasis or myeloma
      • criteria:
        • indication: osteolytic vertebral metastasis or multiple myeloma involving the vertebral body, with severe/intractable pain not relieved by medical therapy (WPS text adds: not involving the major part of the cortical bone)
      • name: Traumatic VCF — WPS (IN) ONLY
      • criteria:
        • state scope: IN only. CGS (KY) publishes NO traumatic indication — denial risk in KY.
        • types: stable/unstable burst fractures; wedge compression fractures; fracture-dislocations (e.g., auto accidents, falls from height)
  • investigational:
    • prophylactic augmentation for spinal osteoporosis (no qualifying acute/subacute fracture)
    • chronic long-standing back pain with old compression fractures — unless pain localizes to a specific chronic fracture AND medical therapy has failed (WPS text)
    • traumatic VCF in KY (CGS text does not address traumatic fractures)
    • fracture with no recent (30-day) advanced-imaging correlation to the pain
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • satisfied by:
    • optimal non-surgical management with persistent NRS/VAS >=5 (non-hospitalized pathway)
    • hospitalized with NRS/VAS >=8 (no NSM prerequisite)
  • modalities named:
    • analgesics (narcotic/non-narcotic)
    • physical therapy modalities
    • bracing / bed rest (immobility methods)
    • anti-osteoporosis therapy
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
Imaging guidance
  • diagnostic: advanced imaging required WITHIN 30 DAYS — MRI marrow edema or bone scan/SPECT/CT uptake at the level
  • intraprocedural:
    • fluoroscopy
    • CT
Quantity limits
  • applies: yes
  • per level: one augmentation per symptomatic fractured level meeting criteria
  • note: >3 vertebral fractures (per procedure) is a relative contraindication; no session-frequency cap otherwise
Contraindications
  • (absolute) current back pain NOT primarily due to the identified acute/subacute VCF
  • (absolute) osteomyelitis, discitis, or active systemic infection (CGS adds surgical-site infection)
  • (absolute for CGS/KY; relative for WPS/IN) pregnancy
  • (relative) >3 vertebral fractures per procedure
  • (relative) allergy to bone cement or opacification agents
  • (relative) uncorrected coagulopathy
  • (relative) spinal instability; myelopathy from the fracture; neurologic deficit; neural impingement; fracture retropulsion / canal compromise
Device / waveformnot_applicable
Payor-specific notes

Governed by each state's "Percutaneous Vertebral Augmentation (PVA) for VCF" LCD — WPS L38213 (IN), CGS L38201 (KY). The osteoporotic gate is SPECIFIC (verified against both bodies 2026-07-24): acute/subacute (<6 wk / 6-12 wk) T1-L5 fracture on RECENT (30-day) advanced imaging (MRI edema or bone-scan/SPECT/CT uptake), AND either hospitalized with NRS/VAS >=8, or non-hospitalized with NRS/VAS >=5 despite optimal non-surgical management plus worsening pain or >=2 qualifying factors (height-loss progression, >25% height reduction, kyphotic deformity, RDQ >17; WPS adds steroid-induced fracture and pre-surgical stabilization), AND the continuum-of-care referrals (BMD evaluation + osteoporosis program). Malignant osteolytic metastasis/myeloma VCF with intractable pain is covered in both states. TRAUMATIC VCF (burst, wedge, fracture-dislocation) is covered by WPS ONLY — the CGS text has no traumatic indication (KY denial risk). Pregnancy is an absolute contraindication for CGS, relative for WPS. 'Point tenderness' is NOT a WPS/CGS criterion (it appears in other MACs' variants — removed from this cell 2026-07-24). Both kyphoplasty (22513-22515) and vertebroplasty (22510-22512) fall under these LCDs. IN/KY billing articles: A57630 (WPS) / A57282 (CGS).

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Maps to WPS L38213 (IN) / CGS L38201 (KY) PVA-for-VCF LCDs (bodies verified 2026-07-24). The note must prove RECENT imaging and the NRS/VAS gate.

.KYPHOMCARE
.KYPHOMCARE

Assessment: *** — osteoporotic vertebral compression fracture at *** (T1-L5), acute (<6
weeks) or subacute (6-12 weeks) by symptom onset, with recent advanced imaging within 30 days
correlating at the level: *** (MRI marrow edema, or bone scan / SPECT-CT uptake). [If
malignant:] osteolytic metastasis or myeloma involving the vertebral body with intractable
pain not relieved by medical therapy. [If traumatic — INDIANA/WPS ONLY:] *** burst / wedge /
fracture-dislocation.

Medical necessity per the Medicare LCD (Percutaneous Vertebral Augmentation for VCF): the
patient is [hospitalized with severe pain at NRS/VAS *** (>=8)] or [non-hospitalized with
NRS/VAS *** (>=5) despite optimal non-surgical management — *** analgesics, physical therapy
modalities, bracing, and anti-osteoporosis therapy — with worsening pain, or >=2 of
height-loss progression, >25% height reduction, kyphotic deformity, and RDQ *** (>17)]. The
patient has been referred for bone-mineral-density evaluation and osteoporosis education and
is enrolled in an osteoporosis prevention and treatment program. No exclusion applies: the
pain arises primarily from the identified VCF; there is no osteomyelitis, discitis, or
systemic infection; [KY: the patient is not pregnant;] <=3 fractures are treated in this
procedure; and there is no uncorrected coagulopathy, instability, myelopathy, neurologic
deficit, neural impingement, or retropulsion with canal compromise.

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

Where this payor diverges from the Medicare baseline

  • diagnosis line (30-day imaging + NRS gate)
  • conservative-care line (NSM vs hospitalized pathway)
  • per-state traumatic coverage

Cautions

  • KY (CGS) has NO traumatic-fracture indication — traumatic VCF is an IN/WPS pathway only. Regenerate if `medicare-in-ky-kyphoplasty.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: no
  • verified: no
  • note: Confirm if furnished hospital-outpatient; not a verified OPD prior-auth category.

Provenance

  • authority:
    • type: lcd
    • title: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
    • lcds:
      • IN: L38213 (WPS, J8) — v11 eff 2024-08-01 (body verified via MCD browser pull 2026-07-24; R4 = typo fixes, no coverage change)
      • KY: L38201 (CGS, J15) — v25 eff 2025-11-20 (body verified via MCD browser pull 2026-07-24; 11/2025 revision = verbiage removal, no coverage change)
    • applies because: WPS (IN) and CGS (KY) each publish this LCD; core osteoporotic criteria align but the texts are NOT fully harmonized (see divergence_note)
    • divergence note: Verified per-state divergences (2026-07-24): (1) TRAUMATIC VCF — WPS covers burst/wedge/fracture-dislocation; CGS text has NO traumatic indication (KY denial risk). (2) Qualifying-factor list — WPS >=2-of-6 (adds steroid-induced fracture + pre-surgical stabilization); CGS >=2-of-4. (3) Pregnancy — ABSOLUTE contraindication for CGS, relative for WPS.
    • billing articles:
      • A57630 (WPS, IN)
      • A57282 (CGS, KY)
  • source: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38213&ver=11
  • effective: 2024-08-01 · payor last reviewed: 2025-11-20 · we verified: 2026-07-24 · v2