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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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. The rules say 
PVA (percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP)) is covered in patients 
with BOTH the following: 
1. Inclusion criteria (ALL are required):  
a. Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) 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
 
b. Symptomatic (ONE): 
i. Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain 
score  8)
4-7
 
ii. Non-hospitalized with moderate-to-severe pain (NRS or VAS 5) despite optimal non-surgical 
management (NSM)
10
* (ONE): 
1. Worsening pain 
2. Stable-to-improved pain (but NRS or VAS still 5) (with  2 of the following): 
A. Progression of vertebral body height loss 
B. > 25% vertebral body height reduction 
C. Kyphotic deformity D. Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire (RDQ) >17) 
*Consider including pedicle periosteal infiltration
7
 
c. Continuum of care
10
 (BOTH): 
1.  
i. All patients presenting with VCF should be referred for evaluation of bone mineral density 
(BMD) and osteoporosis education for subsequent treatment as indicated. 
ii. All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment 
program. 
2. Exclusion criteria (Can have NONE of the following): 
a. Absolute contraindication: 
1.  
i. Current back pain is not primarily due to the identified acute or subacute VCF(s) 
ii. Osteomyelitis, discitis or active systemic or surgical site infection 
iii. Pregnancy 
b. Relative contraindication: 
1.  
i. Allergy to bone cement or opacification agents 
ii. Uncorrected coagulopathy 
iii. Spinal instability 
iv. Myelopathy from the fracture 
v. Neurologic deficit 
vi. Neural impingement 
vii. Fracture retropulsion/canal compromise 
viii. Greater than 3 vertebral fractures 
Vertebral augmentation and kyphoplasty for VCFs with intractable spinal pain not relieved with medical 
therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving a vertebral body. 
You can find this information in Medicares Local Coverage Determination (LCD)  Percutaneous Vertebral 
Augmentation (PVA) for Vertebral Compression Fracture (VCF).