Medicare (Traditional Part A & B) · percutaneous vertebral augmentation

.KYPHOMCARE

Assessment: *** — osteoporotic vertebral compression fracture at *** (T1-L5), acute (<6
weeks) or subacute (6-12 weeks) by symptom onset, with recent advanced imaging within 30 days
correlating at the level: *** (MRI marrow edema, or bone scan / SPECT-CT uptake). [If
malignant:] osteolytic metastasis or myeloma involving the vertebral body with intractable
pain not relieved by medical therapy. [If traumatic — INDIANA/WPS ONLY:] *** burst / wedge /
fracture-dislocation.

Medical necessity per the Medicare LCD (Percutaneous Vertebral Augmentation for VCF): the
patient is [hospitalized with severe pain at NRS/VAS *** (>=8)] or [non-hospitalized with
NRS/VAS *** (>=5) despite optimal non-surgical management — *** analgesics, physical therapy
modalities, bracing, and anti-osteoporosis therapy — with worsening pain, or >=2 of
height-loss progression, >25% height reduction, kyphotic deformity, and RDQ *** (>17)]. The
patient has been referred for bone-mineral-density evaluation and osteoporosis education and
is enrolled in an osteoporosis prevention and treatment program. No exclusion applies: the
pain arises primarily from the identified VCF; there is no osteomyelitis, discitis, or
systemic infection; [KY: the patient is not pregnant;] <=3 fractures are treated in this
procedure; and there is no uncorrected coagulopathy, instability, myelopathy, neurologic
deficit, neural impingement, or retropulsion with canal compromise.

Plan: Percutaneous *** (kyphoplasty 22513 thoracic / 22514 lumbar [+22515 each add'l]; or
vertebroplasty 22510-22512) at level(s) ***, under fluoroscopic/CT guidance. Risks, benefits,
and alternatives discussed; consent obtained.