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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 the decision for treatment should take into consideration the local and general extent of the 
disease, the spinal level involved the severity of pain experienced by the patient as well as his or her neurologic 
condition, previous treatments and their outcomes, the general state of health, and life expectancy. 
 
Percutaneous Vertebroplasty or Vertebral Augmentation including cavity creation is not to be considered a 
prophylactic procedure for osteoporosis of the spine. It also should not be used for chronic back pain of long-
standing duration, even if associated with old compression fractures, unless pain is localized to a specific 
chronic fracture and medical therapy has failed. 
 
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 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). 
 Osteoporotic Conditions 
Painful, debilitating, osteoporotic vertebral collapse/compression fractures, that have not responded to non-
surgical management (e.g. narcotic and/or non-narcotic medication, physical therapy modalities) with or 
without methods of immobility (e.g. bed rest, bracing). 
 
Both PVP and PVA will be considered reasonable and necessary for osteoporotic conditions when ALL of the 
following criteria are met: 
 
Acute (< 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1 - L5) based on symptom onset, and 
documented by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone-
scan/SPECT/CT uptake) and 
The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or visual 
Analog Scale pain score = 8) or is non-hospitalized with moderate to severe pain despite optimal non-surgical 
management (NSM) with one of the following: 

Worsening pain or 
Stable to improved pain 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) 
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. You can find these rules in the 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.