Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57630 (Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57630: Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (Billing and Coding, effective 2024-08-01)
- Covered ICD-10-CM codes
- 91
- 4 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 6
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| C41.2 | — |
| C79.51 | — |
| C79.52 | — |
| C90.00 | — |
| C90.01 | — |
| C90.02 | — |
| C96.5 | — |
| C96.6 | — |
| C96.A | — |
| D16.6 | — |
| D47.1 | — |
| E24.0 | — |
| E24.1 | — |
| E24.2 | — |
| E24.3 | — |
| E24.4 | — |
| E24.8 | — |
| E24.9 | — |
| M48.33 | — |
| M48.34 | — |
| M48.35 | — |
| M48.36 | — |
| M48.37 | — |
| M80.08XA | — |
Procedure codes: 22510, 22511, 22512, 22513, 22514, 22515.
Coverage indications, limitations and medical necessity
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 their 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, and 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
Osteoporotic conditions are defined as 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 ( 1-3, 10,25,27 and
• The beneficiary is symptomatic and is hospitalized with severe pain (Numeric Rating Scale [NRS] or visual Analog Scale [VAS] pain score ≥ 8) 4-7 or is non-hospitalized with moderate to severe pain (NRS or VAS ≥ 5) despite optimal non-surgical management (NSM) 8 with 1 of the following:
• Worsening pain or
• Stable to improved pain (but NRS or VAS ≥ 5) 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 an evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated and instructed to take part in an osteoporosis prevention/treatment program. 8
Malignant Vertebral Fractures
Osteolytic vertebral metastasis or myeloma with severe back pain related to destruction of the vertebral body, not involving the major part of the cortical bone.
• Painful osteolytic metastasis
• Multiple myeloma with painful vertebral body involvement
Traumatic Compression Fractures
Trauma, even minor falls, can produce a spine fracture. Many of these injuries will never require surgery, but major fractures can result in serious long-term problems unless treated promptly and properly. These severe injuries frequently result in spinal instability, with a high risk of spinal cord injury and pain, which can produce a spine fracture. WPS is reinstating coverage of PVA as reasonable and necessary for the following traumatic conditions.
• Stable and/or unstable burst fractures
• Wedge compression fractures
• Fracture-dislocations that occur following auto accidents or falls from height
Limitations
Exclusion criteria for any patient considered for percutaneous vertebroplasty or vertebral augmentation 2,5,8-10 :
• Absolute contraindication
• Current back pain is not primarily due to the identified acute VCF(s).
• Osteomyelitis, discitis, or active systemic infection
• Relative contraindication
• Greater than 3 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
• Pregnancy
Summary of evidence (opening)
Osteoporotic Compression Fractures
Osteoporosis (and low bone mass) affects 50 percent of people over 50 years of age, or over 50 million people in the United States. Its primary impact, fractures (also called fragility or low-trauma fractures), occurs secondary to normal activity (e.g., bending, coughing, lifting, fall from a standing height), and eventually occurs in 50% of women and 20% of men. VCFs constitute one-quarter of osteoporotic fractures, 6 often at the midthoracic (T7-T8) and thoracolumbar junction (T12-L1). They may cause significant acute and chronic pain, leading to complications of impaired mobility comparable to a hip fracture (pneumonia, loss of bone and muscle mass, incidental falls, deep venous thrombosis, depression, and isolation). 10 Medicare claims data shows an 85% 10-year mortality following a VCF diagnosis. 11 Under-diagnosis and under-treatment may exacerbate morbidity and mortality. 8 Vertebral augmentation provides a significant mortality benefit over nonsurgical management with a low number needed to treat (NNT). 43
Treatment options for symptomatic osteoporotic VCF range from NSM (anti-osteoporosis therapy, analgesics, limited activity/bed rest, back brace, physical therapy) to PVA (PVP and percutaneous kyphoplasty [PKP]). PVP involves the percutaneous injection of bone cement under image guidance into the VCF. PKP adds balloon tamponade within the fractured vertebral body to create a low-pressure cavity prior to cement injection. Both treatments aimed to immobilize the fracture, reduce pain, and improve alignment.
Successful small European series introduced PVP into the United States in 1993. By 2007, encouraging preliminary observational data led to medical society endorsement and clinical acceptance in painful osteoporotic VCFs refractory to medical management. Subsequent early open-label randomized controlled trials (RCTs), including the Vertebroplasty for Painful Chronic Osteoporotic Vertebral Fractures (VERTOS) trial, 11 the Fracture Reduction Evaluation (FREE) trial, 12,13 VERTOS II 14 and others, found a benefit of vertebral augmentation over non-surgical management.
The contractor cites 47 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2019-12-16
- Current revision effective
- 2026-07-30
- Last reviewed by the contractor
- 2026-06-24
- MCD version
- 13
Other related documents: A57631 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wisconsin Physicians Service Insurance Corporation hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L38213 cover?
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 their neurologic condition, previous treatments and their outcomes, the general state of health, and life expectancy. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L38213 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L38213?
The companion billing and coding article A57630 lists 91 ICD-10-CM codes in 4 groups that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L38213?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.