Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)

Percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) is covered for osteoporotic vertebral compression fractures when all inclusion criteria are met: an acute/subacute VCF with qualifying pain severity (hospitalized NRS/VAS ≥8 or non-hospitalized NRS/VAS ≥5 despite optimal non‑surgical management) and either worsening pain or persistent NRS/VAS ≥5 with at least two structural/functional findings (e.g., vertebral height loss >25%, kyphotic deformity, RDQ >17). Coverage is excluded for conditions such as infection, pregnancy, or when pain is not primarily due to the identified VCF; several relative contraindications apply (e.g., >3 fractures per procedure, allergy to bone cement, uncorrected coagulopathy, spinal instability, neurologic deficit). Documentation must include diagnosis, pain scores, prior NSM, imaging findings, functional scores, contraindication/risk assessment, and referral for BMD evaluation and osteoporosis education.

"Coverage limited to percutaneous vertebral augmentation (PVA: percutaneous vertebroplasty or percutaneous kyphoplasty) for osteoporotic vertebral compression fracture (VCF)."