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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 (PVP) 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: 
o Acute (<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 computed tomography (SPECT)/computed tomography 
(CT) uptake and 
o 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: 
o Progression of vertebral body height loss 
o > 25% vertebral body height reduction 
o Kyphotic deformity 
o Severe impact of VCF on daily functioning (Roland Morris Disability 
Questionnaire [RDQ] >17) 
Continuum of care: All patients presenting with vertebral compression fractures 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. 
2. 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. 
 
Limitations 
Exclusion criteria  
Absolute contraindication 
- Current back pain is not primarily due to the identified acute or subacute VCF(s). 
- Osteomyelitis, discitis or active systemic infection 
- Pregnancy 
- Active surgical site infection 
 
Relative contraindication 
- Greater than three vertebral fractures per procedure 
- Allergy to bone cement or opacification agents 
- Uncorrected coagulopathy 
- Spinal instability 
- Myelopathy from the fracture 
- Neurologic deficit 
- Neural impingement 
- Fracture retropulsion/canal compromise 
 
You can find this information in the Local Coverage Determination (LCD): 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.