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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. 
 
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 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). 
PVA will be considered reasonable and necessary for osteoporotic conditions when ALL of the following 
criteria are met: 
 Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertebral compression fractures (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)
1-3, 10,25,27
 and 
 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)
4-7
 or is non-hospitalized with moderate to severe pain (NRS or VAS greater than or equal to 5) despite optimal non-surgical 
management (NSM)
8
 with one of the following: 
o Worsening pain or 
o Stable to improved pain (but NRS or VAS greater than or equal to 5) when 2 or more of the 
following are present:  
 Progression of vertebral body height loss 
 Greater than 25% vertebral body height reduction 
 Kyphotic deformity 
 Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire 
(RDQ) greater than 17) 
 Steroid-induced fractures 
 Reinforcement or stabilization of vertebral body prior to surgery 
 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.
8
 
You can find this rule 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.