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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 state that 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. 

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). 
 
Covered Indications 
 
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: 
o Acute (<6 wks) or subacute (6-12 wks)
 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 
o The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating 
Scale [NRS] or Visual Analog Scale [VAS] pain score  8) or is non-hospitalized with moderate to severe pain (NRS or VAS 5) despite optimal non-surgical management (NSM)8
with one of the following: 
 Worsening Pain or 
 Stable to improved pain (but NRS or VAS 5) when 2 or more of the following 
are present: 
o Progression of vertebral body height loss 
o > 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] >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. 

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 
o Current back pain is not primarily due to the identified acute or subacute VCF(s). 
o Osteomyelitis, discitis or active systemic infection 
o Pregnancy 
o Active surgical site infection 
- Relative contraindication 
o Greater than three vertebral fractures per procedure 
o Allergy to bone cement or opacification agents 
o Uncorrected coagulopathy 
o Spinal instability 
o Myelopathy from the fracture 
o Neurologic deficit 
o Neural impingement 
o Fracture retropulsion/canal compromise 

You can find this rule at the Medicare Local Coverage Determination (LCD) L35130: Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF). 
 
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.