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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that PVA (Percutaneous Vertebroplasty (PVP) or Kyphoplasty (PKP)) is covered in patients with 
BOTH the following: 
 
   1. Inclusion criteria (ALL are required): 
        a. Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T5 L5) based on symptom 
onset, and documented by advanced imaging  (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)  
        b. Symptomatic (ONE): 
            i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score 
equals 8)  
            ii. Non-hospitalized with moderate to severe pain (NRS or VAS equals 5) despite optimal non-surgical 
management (NSM)10 (ONE): 
                1. Worsening pain 
                2. Stable to improved pain (but NRS or VAS still equals 5) (with equals 2 of the following): 
                    A. Progression of vertebral body height loss 
                    B. greater than 25% vertebral body height reduction 
                    C. Kyphotic deformity 
                    D. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17 
        c. Continuum of care (Both) 
            i. All patients presenting with VCF should be referred for evaluation of BMD and osteoporosis 
education for subsequent treatment as indicated.  
            ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program.  
 
    2. Exclusion criteria (Can have NONE of the following): 
        a. Absolute contraindication 
           i. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
           ii. Osteomyelitis, discitis or active systemic or surgical site infection 
           iii. Pregnancy 
         
 
 
        b. Relative contraindication 
           i. Greater than three vertebral fractures per procedure 
           ii. Allergy to bone cement or opacification agents 
           iii. Uncorrected Coagulopathy 
           iv. Spinal instability 
           v. Myelopathy from the fracture 
           vi. Neurologic deficit 
           vii. Neural impingement 
           viii. Fracture retropulsion/canal compromise 
 
You can find this information in Medicare's FUTURE Local Coverage Determination (LCD): Percutaneous 
Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (L34106). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.