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

Percutaneous vertebral augmentation (vertebroplasty or kyphoplasty) is covered for acute or subacute osteoporotic vertebral compression fractures when all inclusion criteria are met: documented imaging-confirmed VCF, symptomatic pain meeting NRS/VAS thresholds (>=8 hospitalized; >=5 non-hospitalized despite optimal NSM), and either worsening pain or NRS>=5 plus at least two structural/functional findings (e.g., >25% vertebral height loss, kyphotic deformity, RDQ>17, severe functional impact). Coverage excludes active infection, pregnancy, pain not primarily due to the identified VCF, and several relative contraindications (e.g., >3 fractures per procedure, allergy to cement/contrast, uncorrected coagulopathy, spinal instability or neurologic compromise); documentation must include pain scores, imaging, prior NSM, functional assessments, and records of BMD referral/osteoporosis education.

"Acute or subacute osteoporotic vertebral compression fracture (VCF) documented by imaging."