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 (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: 
   - 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 
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) or is non-hospitalized with moderate to 
severe pain (NRS or VAS greater than or equal to 5) despite optimal non-surgical management (NSM) with 
one of the following: 
      - Worsening Pain or 
      - 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) 
 
All patients presenting with 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. 
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.  
1. 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) (L35130). 
 
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.