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 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 Percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for the following indications: 
 
   1. Painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those that have not 
responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, physical 
therapy modalities) with and without methods of immobility (e.g. rest, bracing). 
        Both PVP and PVA will be considered reasonable and necessary when ALL of the following criteria are 
met: 
            Acute (less than 6 wks) or subacute (6-12 wks)18,28,42 osteoporotic VCF (T5 ? L5) confirmed by 
recent (within 30 days) advanced imaging demonstrating bone marrow edema on MRI or bone-
scan/SPECT/CT uptake and 
            The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or 
Visual Analog Scale [VAS] pain score equals 8) or is non-hospitalized with moderate to severe pain (NRS or 
VAS equals 5) despite optimal non-surgical management (NSM)8 with one of the following: 
                Worsening Pain or 
                Stable to improved pain (but NRS or VAS equals 5) when 2 or more of the following are present: 
                    Progression of vertebral body height loss 
                    greater than 25% vertebral body height reduction 
                    Kyphotic deformity 
                    Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) 
greater than 17) 
 
    Continuum of care 
 
    All patients presenting with vertebral compression fractures (VCF) should be referred for evaluation of bone 
mineral density and osteoporosis education for subsequent treatment as indicated and instructed to take part in 
an osteoporosis prevention/treatment program.8 
    2. Malignant Vertebral Fractures 
    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. 
 
Limitations 
 
    1. Exclusion criteria 
 
        Absolute contraindication 
            Current back pain is not primarily due to the identified acute or subacute VCF(s). 
            Osteomyelitis, discitis or active systemic infection 
            Pregnancy 
            Greater than three vertebral fractures 
 
 
 
        Relative contraindication 
            Allergy to bone cement or opacification agents 
            Uncorrected coagulopathy 
            Spinal instability 
            Myelopathy from the fracture 
            Neurologic deficit 
            Neural impingement 
            Fracture retropulsion / canal compromise 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.