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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 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). 
A. Both PVP and PVA will be considered reasonable and necessary when ALL of the following 
criteria are met: 
a. Acute (Less than 6 weeks) or subacute (6-12 weeks) 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 
b. The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale 
[NRS] or Visual Analog Scale [VAS] pain score greater than or equal to 8) or is non-
hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite 
optimal non-surgical management (NSM) with one of the following: 
 Worsening Pain or 
 Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or 
more of the following are present: 
o Progression of vertebral body height loss 
o Greater than 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] greater than 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. 

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. 

The following are limitations 

1. Exclusion criteria  
A. Absolute contraindication 
a. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
b. Osteomyelitis, discitis or active systemic infection 
c. Pregnancy 
d. Active surgical site infection 
B. Relative contraindication 
a. Greater than three vertebral fractures per procedure 
b. Allergy to bone cement or opacification agents 
c. Uncorrected coagulopathy 
d. Spinal instability 
e. Myelopathy from the fracture 
f. Neurologic deficit 
g. Neural impingement 
h. Fracture retropulsion/canal compromise 

You can find this rule in the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF), L34976. 
 
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.