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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 both percutaneous vertebroplasty (PVP) and percutaneous vertebral augmentation (PVA) 
will be considered reasonable and necessary for osteoporotic conditions when ALL of the following criteria are 
met: 
- Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1  
L5) based on symptom onset, and documented by recent (within 30 days) advanced imaging (bone 
marrow edema on magnetic resonance imaging (MRI) or bone-scan/single photon emission computed 
tomography (SPECT)/computed tomography (CT) uptake) and 
- 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) 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: 
- Progression of vertebral body height loss 
- >25% vertebral body height reduction 
- Kyphotic deformity 
- Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire 
(RDQ) > 17) 
- Steroid-induced fractures 
- Reinforcement or stabilization of vertebral body prior to surgery 
 
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. 
1. Painful osteolytic metastasis 
2. 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. 
1. Stable and/or unstable burst fractures 
2. Wedge compression fractures 
3. Fracture-dislocations that occur following auto accidents or falls from height 
 
Limitations 
Exclusion criteria for any patient considered for percutaneous vertebroplasty or vertebral augmentation 
1. Absolute contraindication 
- Current back pain is not primarily due to the identified acute VCF(s). 
- Osteomyelitis, discitis, or active systemic infection 
2. 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 the 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.