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

Percutaneous vertebral augmentation (vertebroplasty/kyphoplasty) is covered for malignant or non‑malignant thoracic/lumbar (T5–L5) compression fractures or pre‑surgical stabilization of ≤2 levels when there is concordant advanced imaging, significant daily pain (VAS/NRS ≥7 or described as severe) and either acute incapacitating pain or subacute pain that failed 4 weeks each of prescription analgesics/steroids/NSAIDs and a provider‑directed exercise program; urgent/emergent malignant cases are allowed with confirmatory advanced imaging without prior conservative treatment. Excluded/not medically necessary are cervical/T1–T4 levels, sacroplasty for sacral insufficiency, prophylactic or chronic non‑painful indications, vertebra plana, burst/unstable fractures, active infection/sepsis/osteomyelitis, uncorrected coagulopathy, cord compression/extensive vertebral destruction, prohibition on Norian XR/SRS cements, and other listed contraindications; documentation of imaging (≤6 months), pain severity, functional impairment, conservative therapy for subacute cases, spine‑surgeon availability for emergencies, and prior authorization are required.