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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 the decision for treatment should take into consideration the local and general extent of the 
disease, the spinal level involved the severity of pain experienced by the patient as well as his or her neurologic 
condition, previous treatments and their outcomes, the general state of health, and life expectancy. 
 
Percutaneous Vertebroplasty or Vertebral Augmentation including cavity creation is not to be considered a 
prophylactic procedure for osteoporosis of the spine. It also should not be used for chronic back pain of long-
standing duration, even if associated with old compression fractures, unless pain is localized to a specific 
chronic fracture and medical therapy has failed. 
 
Percutaneous vertebroplasty (PVP) is a therapeutic, interventional neurosurgical and radiological procedure 
that consists of the percutaneous injection of a biomaterial, methyl methacrylate, into a lesion of a thoracic or 
lumbar vertebral body. The procedure is utilized for pain relief and bone strengthening of weakened vertebral 
bodies. The procedure is performed under fluoroscopic guidance, although some prefer the use of computed 
tomography (CT) with fluoroscopy for needle positioning and injection assessment. An intraosseous venogram 
is sometimes performed before cement injection to determine whether the needle is positioned within a direct 
venous anastomosis to the central or epidural veins, to minimize extravasation into venous structures. 
Conscious sedation with additional local anesthesia (1 percent lidocaine) is generally utilized; however, 
patients who experience difficulties with ventilation or are unable to tolerate prone position during the 
procedure may require general anesthesia or deep sedation with airway and ventilation support. The methyl 
methacrylate is injected into the vertebral body until resistance is met or until cement reaches the posterior 
wall. 
 
Percutaneous Vertebral Augmentation Percutaneous vertebral augmentation (PVA) is a minimally invasive 
procedure for the treatment of compression fractures of the vertebral body. The procedure includes the creation 
of a cavity, which results in fracture reduction along with an attempt to restore vertebral body height and 
alignment. Using imaging guidance x-rays, incisions are made, and a probe is placed into the vertebral space in 
the location of the fracture. The collapsed vertebral body is drilled and a device, which displaces, removes, or 
compacts the compressed area of the vertebrae, is used to create a cavity prior to injection of the bone filler 
(polymethylmethacrylate) (PMMA).  
Osteoporotic Conditions 
Painful, debilitating, osteoporotic vertebral collapse/compression fractures, that have not responded to non-
surgical management (e.g. narcotic and/or non-narcotic medication, physical therapy modalities) with or 
without methods of immobility (e.g. bed rest, bracing). 
 
Both PVP and PVA will be considered reasonable and necessary for osteoporotic conditions when ALL of the 
following criteria are met: 
 
    Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 - L5) based on symptom onset, 
and documented by recent (within 30 days) advanced imaging (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) 
            Steroid-induced fractures 
            Reinforcement or stabilization of vertebral body prior to surgery 
    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 
 
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. 
 
    Painful osteolytic metastasis 
    Multiple myeloma with painful vertebral body involvement 
 
Traumatic Compression Fractures 
Trauma, even minor falls, can produce a spine fracture. Many of these injuries will never require surgery, but 
major fractures can result in serious long-term problems unless treated promptly and properly. These severe 
injuries frequently result in spinal instability, with a high risk of spinal cord injury and pain, which can produce 
a spine fracture. WPS is reinstating coverage of PVA as reasonable and necessary for the following traumatic 
conditions. 
 
    Stable and/or unstable burst fractures 
    Wedge compression fractures 
    Fracture-dislocations that occur following auto accidents or falls from height 
 
Limitations 
Exclusion criteria for any patient considered for percutaneous vertebroplasty or vertebral augmentation: 
 
    Absolute contraindication         Current back pain is not primarily due to the identified acute VCF(s). 
        Osteomyelitis, discitis, or active systemic infection 
    Relative contraindication 
        Greater than three vertebral fractures per procedure 
        Allergy to bone cement or opacification agents 
        Uncorrected coagulopathy 
        Spinal instability 
        Myelopathy from the fracture 
        Neurologic deficit 
        Neural impingement 
        Fracture retropulsion/canal compromise 
        Pregnancy 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L38213). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.