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UnitedHealthcare (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 body fracture/lesion within 4 months of onset, failed optimal medical therapy
      • criteria:
        • onset window: within 4 months of pain onset
        • functional impairment: required
        • etiologies:
          • osteoporotic VCF
          • steroid-induced fracture
          • osteolytic metastatic disease
          • multiple myeloma
          • vertebral hemangioma with aggressive features
          • unstable osteonecrosis (Kummell)
        • imaging: CT/MRI rules out other pain causes (foraminal stenosis, HNP, other generators)
  • excluded must be absent:
    • spinal cord compression on CT/MRI
    • significant collapse/destruction (vertebra <1/3 original height)
    • healed VCF; asymptomatic VCF; VCF responding to conservative therapy
    • sacral/coccygeal lesions
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • satisfied by:
    • failed Optimal Medical Therapy within the 4-month window
    • contraindicated
  • modalities named:
    • analgesics / medical therapy
    • activity modification
    • bracing
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: no
Payor-specific notes

UHC commercial vertebral augmentation policy. Covers a painful vertebral fracture/lesion WITHIN 4 MONTHS of pain onset that has failed optimal medical therapy (osteoporotic, steroid-induced, osteolytic mets, myeloma, aggressive hemangioma, Kummell), with CT/MRI excluding other pain causes. KEY divergence from Medicare: a hard <=4-month onset window, and it does NOT require MR marrow-edema / STIR or bone-scan positivity (which the Medicare LCDs emphasize). Excluded: cord compression, severe collapse (vertebra reduced to <1/3 of its original height), healed/asymptomatic VCF, sacral/coccygeal lesions. From the actual fetched UHC PDF.

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Dot phrase

Self-contained narrative A&P attestation. `***` = fill-in. Maps to UHC commercial policy 2026T0581Q (Percutaneous Vertebroplasty and Kyphoplasty). The hard gate is the <=4-MONTH onset window — date the pain onset in the note.

.KYPHOUHC
.KYPHOUHC

Assessment: *** — painful vertebral body fracture or lesion at ***, WITHIN 4 MONTHS of pain
onset (onset ***), with functional impairment. Etiology: *** (osteoporotic VCF /
steroid-induced fracture / osteolytic metastatic disease / multiple myeloma / vertebral
hemangioma with aggressive features / unstable osteonecrosis [Kummell]). CT/MRI on *** rules
out other causes of pain including foraminal stenosis, disc herniation, and other generators.

Medical necessity per UHC 2026T0581Q: optimal medical therapy within the 4-month window has
failed or was contraindicated — analgesics and medical therapy, activity modification, and
bracing: *** . All exclusions are absent: there is no spinal cord compression on CT/MRI, no
significant collapse or destruction (the vertebra is NOT reduced to <1/3 of its original
height), the fracture is not healed, not asymptomatic, and not responding to conservative
therapy, and this is not a sacral or coccygeal lesion.

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.

Where this payor diverges from the Medicare baseline

  • diagnosis line (<=4-month onset window; no MR-edema requirement)
  • conservative-care line (failed optimal medical therapy; no week floor)
  • exclusions (must-be-absent list incl. vertebra <1/3 height)

Cautions

  • Prior auth not stated in-policy — governed by a separate UHC PA list; verify before scheduling. UHC does NOT require MR marrow edema (unlike Medicare). Regenerate if `uhc-commercial-kyphoplasty.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: not stated in the policy
  • note: not stated in-policy; governed by a separate UHC PA list

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
  • 2026-07-23kyphoplasty/uhc: prose said '>1/3 height loss' — source says vertebra <1/3 original height 5d96842aa2
  • 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