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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. 
 
The procedure is performed under fluoroscopic guidance, although some prefer the use of computed 
tomography (CT) with fluoroscopy for needle positioning and injection assessment. An intraosseous venogram 
is sometimes performed before cement injection to determine whether the needle is positioned within a direct 
venous anastomosis to the central or epidural veins, to minimize extravasation into venous structures. 
Conscious sedation with additional local anesthesia (1% lidocaine) is generally utilized; however, patients who 
experience difficulties with ventilation or are unable to tolerate prone position during the procedure may 
require general anesthesia or deep sedation with airway and ventilation support. The methyl methacrylate is 
injected into the vertebral body until resistance is met or until cement reaches the posterior wall. 
 
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: 
        * Acute (<6 wks) or subacute (6-12 wks) osteoporotic vertebral compression fracture (VCF) (T1 L5), 
based on symptom onset, and documented by advanced imaging demonstrating bone marrow edema on MRI or 
bone-scan/a single-photon emission computerized tomography (SPECT)/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) 
 
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. 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.