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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 that Provisions in this LCD and related coding article only address Vertebral Augmentation for 
Osteoporotic Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary 
procedures for other conditions not included in this LCD. 
 
PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with BOTH the 
following: 
 
1. Inclusion criteria (ALL are required):  
 
    a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) by recent (within 30 days) 
advanced imaging (bone marrow edema on MRI or bone-scan/SPECT/CT uptake)1-3,10,25,27 
    b. Symptomatic (ONE): 
        i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 
8)4-7 
       ii. Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical 
management (NSM)10* (ONE): 
            1. Worsening pain 
            2. Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
                  a. Progression of vertebral body height loss 
                  b. > 25% vertebral body height reduction 
                  c. Kyphotic deformity 
                  d. Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire (RDQ) >17) 
 
                       * consider including pedicle periosteal infiltration7 
 
    c. Continuum of care10 (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 criteria2,5,8-10 (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. Allergy to bone cement or opacification agents 
       ii. Uncorrected coagulopathy 
      iii. Spinal instability 
      iv. Myelopathy from the fracture 
       v. Neurologic deficit 
      vi. Neural impingement 
     vii. Fracture retropulsion/canal compromise 
    viii. Greater than three vertebral fractures 
 
Osteoporosis (and low bone mass) affects 50 percent of people over 50 years of age, or over 50 million people 
in the United States. Its primary impact, fractures (also called fragility or low-trauma fractures), occurs 
secondary to normal activity (e.g., bending, coughing, lifting, fall from a standing height), and eventually 
occurs in 50% of women and 20% of men. VCFs constitute one-quarter of osteoporotic fractures,6 often at the 
midthoracic (T7-T8) and thoracolumbar junction (T12-L1). They may cause significant acute and chronic pain, 
leading to complications of impaired mobility (comparable to a hip fracture, pneumonia, loss of bone and 
muscle mass, incidental falls, deep venous thrombosis, depression, and isolation).10 Medicare claims data 
shows a 85% 10 year mortality following a VCF diagnosis.11 Under-diagnosis and under-treatment may 
exacerbate morbidity and mortality.10 Vertebral augmentation provides a significant mortality benefit over 
nonsurgical management with a low number needed to treat (NNT). 
 
Treatment options for symptomatic osteoporotic VCF range from NSM (anti-osteoporosis therapy, analgesics, 
limited activity/bed rest, back brace, physical therapy) to PVA (PVP and PKP). PVP involves the percutaneous 
injection of bone cement under image guidance into the VCF. PKP adds balloon tamponade within the 
fractured vertebral body to create a low-pressure cavity prior to cement injection. Both treatments aimed to 
immobilize the fracture, reduce pain, and improve alignment 
 
Successful small European series introduced PVP into the United States in 1993; by 2007 encouraging 
preliminary observational data led to medical society endorsement and clinical acceptance in painful 
osteoporotic VCFs refractory to medical management. Subsequent early open label randomized controlled 
trials (RCTs), including the Vertebroplasty for Painful Chronic Osteoporotic Vertebral Fractures (VERTOS) 
trial,21 the Fracture Reduction Evaluation (FREE) trial,22,23 VERTOS II,14 and others, found a benefit of 
vertebral augmentation over non-surgical management. 
 
You can find this rule in the Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) L38737. 
 
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.