Appeal type: unknown
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 at42 CFR422.101. The rules say that there is only one indication for these procedures: treatment of acute (< 4 months of symptoms) and painful compression fracture(s), regardless of etiology, in a patient without contraindication due to neurological deficits:-The fracture may be demonstrated by plain film, CT or by MRI. The findings must correlate unequivocally with the site of the patient's pain as demonstrated by physical examination.-Acuity may be established by history, MRI and/or nuclear medicine bone scan.-Pain must be predominantly related to the demonstrated fracture(s), of moderate to severe intensity (e.g., pain level at least 6 on VAS 1-10), such that the patient cannot perform basic activities of daily living (ADLs), such as ambulation, sitting, bathing, transfers.-Pain must be refractory to conservative measures employed for reasonable periods of time, such as medication management with appropriate titration. Generally, procedures are not medically reasonable and necessary when performed immediately after the fracture occurs. Exceptions will not be allowed unless the medical record establishes a clear rationale for the exception. For example, "adequate pain control impairs basic ADLs" or "is associated with respiratory compromise.-If pain may be due to one or more conditions, prior to any vertebral augmentation procedure, an appropriately comprehensive pain assessment and consequent pain management treatment plan must be instituted. Other probable causes of pain must be reasonably excluded. The treatment plan must begin with the least invasive approach that addresses identified pain generators; potentially, an implantable pump for analgesia or surgical stabilization in a patient with concurrent instability.-An interval assessment by the proceduralist is an absolute requirement if the procedure is performed by any provider other than the diagnostician who performed the pain assessment and developed the plan of care. The proceduralist must document the rationale for proceeding with treatment in the medical record.-The medical record must contain a detailed operative procedure narrative report. "Boilerplate" or other non-specific "canned" reports does not fulfill this requirement.-While treatment of only one to two levels would be anticipated, treatment of no morethan three (3) vertebral levels within the range of T1-L5 may be covered and reimbursed during the entire episode of pain caused by or related to an acute compression fracture(s), regardless of the number of fractures. Hence, if more than three acute fractures are present, alternative therapies must be employed. Treatment of three levels may be subject to pre-or post-pay review. Exceptions: steroid-induced osteoporosis and multiple myeloma when conservative measures have been demonstrated to be inadequatein the specific patient and result in the inability to perform basic ADLs.-Procedures must be performed with real-time CT or fluoroscopic imaging guidance, Images of final trocar placement and appearance of the vertebral body at the end of the procedure must be available on request.-No percutaneous vertebral augmentation procedure, such as sacroplasty, is indicated for treatment of lesions of the sacrum or coccyx.You can find this rule in Local Coverage Determination (LCD): Percutaneous Vertebral Augmentation (L34106) -Effective December 1, 2019.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.