Medicare prior authorization · 22512

22512 — Percutaneous Vertebral Augmentation for Vertebral Compression Fracture

Subject to WISeR prior authorization or pre-payment review in AZ, NJ, OH, OK, TX, WA for dates of service 2026-01-15 through 2031-12-31, in hospital outpatient, ambulatory surgical center, office and home settings. The decision is made on Medicare’s existing coverage policy; nothing in these programs changes what is covered.

WISeR

Decision: 3 days; 2 days expedited; unlimited resubmissions
If no request is made: the claim goes to pre-payment medical review
Policies CMS cites (Appendix A): L34228 · L38201 · L35130
Participant by state: AZ: Zyter · NJ: Genzeon · OH: Innovaccer · OK: Humata Health · TX: Cohere Health · WA: Virtix Health
Exemption: NPI-level, after ≥10 requests and the participant’s affirmation-rate threshold in an assessment period; granted quarterly from July 2026; held at least a year.

What CMS lists for the record

From the WISeR Operational Guide, verbatim. The coverage policy governs; use the check below for the diagnosis and state.

CMS WISeR documentation checklist · §6.2.9

Operational Guide v7.0, last updated July 24, 2026 · retrieved 2026-09-14

Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34228, L38201, L35130)

CMS: “To meet coverage criteria, the patient’s medical record must contain documentation that fully supports the medical necessity of services. Subsections 6.2.1 to 6.2.13 list the documentation requirements for example services. For detailed documentation requirements, providers who choose to submit a prior authorization request for a WISeR Select Item or Service should refer to the relevant NCDs and/or their MAC jurisdiction’s LCDs and Local Coverage Articles (LCAs), if available, for guidance. They can be found on the Medicare Coverage Database website.”

General documentation requirements for Percutaneous Vertebroplasty Augmentation (PVA) (Percutaneous Vertebroplasty [PVP] or Kyphoplasty [PKP]) are as follows:

For painful, debilitating, osteoporotic, vertebral, collapse/compression fractures, the following requirements should be met: a) Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic VCF (T1–L5) based on symptom onset and documented by advanced imaging (bone marrow edema on MRI or bone-scan/single-photon emission computed tomography (SPECT)/computed tomography (CT) uptake) b) Hospitalized with severe pain, defined as a Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score greater than or equal to 8 OR non-hospitalized with moderate to severe pain, defined as a NRS or VAS pain score greater than or equal to 5, despite optimal non-surgical management (e.g., narcotic and/or non-narcotic medication, physical therapy modalities), with and without methods of immobility (e.g., rest, bracing). For non-hospitalized patients, one of the following must be documented: o Worsening pain OR o Stable to improved pain (but NRS or VAS score remains greater than or equal to 5), with at least 2 of the following: 1. Progression of vertebral body height loss 2. More than 25% vertebral body height reduction 3. Kyphotic deformity 4. Severe impact of VCF on daily functioning, indicated by a Roland Morris Disability Questionnaire (RDQ) score greater than 17 c) Documentation of referral for evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated d) Documentation of instruction to participate in an osteoporosis prevention/treatment program
For malignant vertebral fracture, documentation that the patient has an osteolytic vertebral, metastasis, or myeloma with severe back pain related to a destruction of the vertebral body, not involving the major part of the cortical bone
Assessment and documentation of none of the following: a) Current back pain is not primarily due to the identified acute or subacute VCF(s) b) Osteomyelitis, discitis, or active systemic or surgical site infection c) Pregnancy
Assessment of the following relative contraindications and rationale for proceeding with PVA if one or more of the following exist: a) Greater than three vertebral fractures per procedure b) Allergy to bone cement or opacification agents c) Uncorrected coagulopathy d) Spinal instability e) Myelopathy from the fracture f) Neurologic deficit g) Neural impingement h) Fracture retropulsion/canal compromise

Read the guide on CMS →

The coverage policy the reviewer applies, by state

Each state’s Medicare contractor writes its own LCD, so the policy that decides a 22512 request depends on the state. The documentation requirements below are quoted from the policy or its Billing & Coding article as captured; the linked CMS document is authoritative.

AZ, WA · Noridian

L34228 — Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) — Noridian · CMS version 54 · captured 2026-07-25

Billing & Coding articles: A58535 · A58534 · A56572

Documentation requirements · A56572
“The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.”

OH · CGS Administrators

L38201 — Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) — CGS · CMS version 25 · captured 2026-07-25

Billing & Coding articles: A58462 · A57282

Read the documentation requirements in the linked CMS document.

NJ, OK, TX · Novitas

L35130 — Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) — Novitas · CMS version 66 · captured 2026-09-12

Billing & Coding articles: A58685 · A57752

Documentation requirements · A57752
“All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.”

Check 22512 for your state, diagnosis and setting

The governing policy as it stands today, whether the diagnosis is on its list, and the documentation the policy’s own text requires — quoted, source-linked, free.

Run the check →

Full lists: WISeR code list · WISeR rules and exemption

Same family: 22510 · 22511 · 22513 · 22514 · 22515

Sources: CMS WISeR Provider and Supplier Operational Guide v7.0 (2026-07-24), Appendix A; CMS list of OPD services requiring prior authorization (2024-08-05); CMS list of ambulatory surgical center services for prior authorization (2026-03-05) and the ASC Operational Guide (2026-03-03). Codes are shown as numbers only, as CMS lists them. CPT® is a registered trademark of the American Medical Association.