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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 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). 
 
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 (<6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fracture (VCF) (T1 L5), based 
on symptom onset, and documented by advanced imaging demonstrating bone marrow edema on magnetic 
resonance imaging (MRI) or bone-scan/single-photon emission computerized 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) 
Continuum of care 
 
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 these rules in the Local Coverage Determination (LCD) Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) L35130. 
 
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.