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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 PVA (percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
 
Inclusion criteria (ALL are required): 
Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1  L5), 
based on symptom onset, and documented by advanced imaging (bone marrow edema on magnetic resonance 
imaging (MRI) or bone-scan/single-photon emission computerized tomography (SPECT)/computed 
tomography (CT) uptake)  
Symptomatic (ONE): 
Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score = 8)  
Non-hospitalized with moderate to severe pain (NRS or VAS =5) despite optimal non-surgical management 
(NSM) (ONE): 
Worsening pain 
Stable to improved pain (but NRS or VAS still =5) (with = 2 of the following): 
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 
Continuum of care (Both)  
All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and 
osteoporosis education for subsequent treatment as indicated. 
All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program. 
Exclusion criteria (Can have NONE of the following):   
 
Absolute contraindication 
Current back pain is not primarily due to the identified acute or subacute VCF(s). 
Osteomyelitis, discitis, active systemic or surgical site infection 
Pregnancy 
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 
 
Summary of Evidence 
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). Medicare claims data shows 
an 85% 10-year mortality following a VCF diagnosis. Under-diagnosis and under-treatment may exacerbate 
morbidity and mortality. 
 
You can find these rules in the Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Osteoporotic Vertebral Compression Fracture (VCF) L33569. 
 
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.