CMM-607: Primary Vertebral Augmentation Percutaneous Vertebroplasty/Kyphoplasty) and Sacroplasty

Percutaneous vertebroplasty/kyphoplasty is covered only for painful, imaging‑confirmed osteoporotic/osteolytic compression fractures, metastatic or primary bone malignancy, aggressive vertebral lesions, Kummel disease, steroid‑induced fractures, or pre‑surgical stabilization—limited to a maximum of two levels between T5–L5 per date of service—while cervical/T1–T4 procedures, sacroplasty/coccygeoplasty, prophylactic augmentation, spinoplasty and many other uses are excluded or investigational. Key requirements are recent (≤6 months) confirmatory imaging, documented persistent debilitating pain (VAS/NRS ≥7 plus functional impairment or acute incapacitating pain), and for subacute cases failure of a 4‑week trial of prescription analgesics plus a 4‑week provider‑directed exercise program; standard contraindications (e.g., uncorrected coagulopathy, active infection, severe vertebral destruction or cord compression) also preclude coverage.

"Septicemia and any active infection (including urinary tract infection [UTI])"