Appeal type: unknown
Decision: unknown

 
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 and percutaneous vertebral augmentation (PVA or Kyphoplasty) 
procedures will be considered medically reasonable and necessary for 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). It will be considered reasonable and necessary when ALL of the 
following criteria are met: 
 
1. Acute (less than 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)/CT uptake, and 
2. The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score 8 or more) or is non-hospitalized with moderate to severe pain (NRS or VAS 5 
or more) despite optimal non-surgical management (NSM) with one of the following: 
 
a. Worsening pain, or 
b. Stable to improved pain (but NRS or VAS 5 or more) when two or more of the following are present: 
 
-Progression of vertebral body height loss 
-More than 25% vertebral body height reduction 
-Kyphotic deformity 
-Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] more than 17) 
 
You can find this rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation 
(PVA) for Vertebral The rules say that percutaneous vertebroplasty and percutaneous vertebral augmentation 
(PVA or Kyphoplasty) procedures will be considered medically reasonable and necessary for 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). It will be considered reasonable and necessary when ALL of the following criteria are met: 
 
1. Acute (less than 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)/CT uptake, and 
2. The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or Visual 
Analog Scale [VAS] pain score 8 or more) or is non-hospitalized with moderate to severe pain (NRS or VAS 5 
or more) despite optimal non-surgical management (NSM) with one of the following: 
 
a. Worsening pain, or 
b. Stable to improved pain (but NRS or VAS 5 or more) when two or more of the following are present: 
 
-Progression of vertebral body height loss 
-More than 25% vertebral body height reduction 
-Kyphotic deformity 
-Severe impact of VCF on daily functioning (Roland Morris Disability Questionnaire [RDQ] more than 17) 
 
You can find this rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38201) - Effective July 11, 2021. 
 
The rules say that the exclusion criteria for the requested procedure is: 
 
a. Absolute contraindication 
  
1. Current back pain is not primarily due to the identified acute or subacute VCF(s). 
2. Osteomyelitis, discitis or active systemic infection 
3. Pregnancy 
4. Active surgical site infection 
 
b. Relative contraindication 
 
1. Greater than three vertebral fractures per procedure 
2. Allergy to bone cement or opacification agents 
3. Uncorrected coagulopathy 
4. Spinal instability 
5. Myelopathy from the fracture 
6. Neurologic deficit 
7. Neural impingement 
8. Fracture retropulsion/canal compromise 
 
You can find this rule in the Local Coverage Determination (LCD) - Percutaneous Vertebral Augmentation 
(PVA) for Vertebral Compression Fracture (VCF) (L38201). 
 
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.