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 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 
Covered Indications   
 
Percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) procedures will 
be considered medically reasonable and necessary for the following indications: 
 
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 (T1 L5), based on symptom onset, 
and documented by 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 percent 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. 
 
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 
 
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 
Active surgical site 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 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L34976). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.