Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11201 | Palmetto GBA | A and B and HHH MAC | SC |
| 11301 | Palmetto GBA | A and B and HHH MAC | VA |
| 11401 | Palmetto GBA | A and B and HHH MAC | WV |
| 11501 | Palmetto GBA | A and B and HHH MAC | NC |
| 11202 | Palmetto GBA | A and B and HHH MAC | SC |
| 11302 | Palmetto GBA | A and B and HHH MAC | VA |
| 11402 | Palmetto GBA | A and B and HHH MAC | WV |
| 11502 | Palmetto GBA | A and B and HHH MAC | NC |
| 10111 | Palmetto GBA | A and B MAC | AL |
| 10211 | Palmetto GBA | A and B MAC | GA |
| 10311 | Palmetto GBA | A and B MAC | TN |
| 10112 | Palmetto GBA | A and B MAC | AL |
| 10212 | Palmetto GBA | A and B MAC | GA |
| 10312 | Palmetto GBA | A and B MAC | TN |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A58275 (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.
A58275: Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (Billing and Coding, effective 2022-08-21)
- Covered ICD-10-CM codes
- 13
- 2 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 | — |
| C90.00 | — |
| C90.02 | — |
| M80.08XA | — |
| M80.08XG | — |
| M80.08XK | — |
| M80.08XP | — |
| M80.08XS | — |
| M80.88XA | — |
| M80.88XS | — |
| M84.58XA | — |
| M84.58XS | — |
Procedure codes: 22510, 22511, 22512, 22513, 22514, 22515.
Coverage indications, limitations and medical necessity
PVA (percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP)) is covered in patients who qualify based on the following criteria :
1. Inclusion criteria ( ALL are required ):
• Acute ( 1-3,10,25,27
• Symptomatic ( ONE ):
• Hospitalized with severe pain (Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) pain score ≥8) 4-7
• Non-hospitalized with moderate-to-severe pain (NRS or VAS ≥5) despite optimal non-surgical management (NSM) 10 * ( ONE ):
• Worsening pain
• Stable-to-improved pain (but NRS or VAS still ≥5) ( with ≥ 2 of the following ):
• 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)
*Consider including pedicle periosteal infiltration 7
c. Continuum of care 10 (BOTH) :
• All patients presenting with VCF should be referred for evaluation of bone mineral density (BMD) and osteoporosis education for subsequent treatment as indicated.
• All patients with VCF should be instructed to take part in an osteoporosis prevention/treatment program.
2. Exclusion criteria 2,5,8-10 :
a. Absolute contraindication:
• Current back pain is not primarily due to the identified acute or subacute VCF(s)
• Osteomyelitis, discitis or active systemic or surgical site infection
• Pregnancy
b. Relative contraindication:
• Allergy to bone cement or opacification agents
• Uncorrected coagulopathy
• Spinal instability
• Myelopathy from the fracture
• Neurologic deficit
• Neural impingement
• Fracture retropulsion/canal compromise
• Greater than 3 vertebral fractures
Vertebral augmentation and kyphoplasty for VCFs with intractable spinal pain not relieved with medical therapy will be covered for osteolytic vertebral metastatic disease or myeloma involving a vertebral body.
Summary of evidence (opening)
Osteoporosis (and low bone mass) affects 50% 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. 10 Vertebral augmentation provides a significant mortality benefit over nonsurgical management with a low number needed to treat (NNT).
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 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 aim 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, 21 the Fracture Reduction Evaluation (FREE) trial, 22,23 VERTOS II, 14 and others, found a benefit of vertebral augmentation over NSM.
VERTOS II was a multicenter RCT that compared PVP and NSM of acute ( 14 Among 202 patients, the primary endpoint of pain relief at 1 month and 1 year was greater after PVP (-5.2/-5.7) than after NSM (-2.7/-3.7) (p 15 The authors acknowledged that despite the VERTOS II results, “clinicians still do not know how to best treat their patients,” but conclude that, pending further RCTs, PVP may be justified in patients with insufficient pain relief after 3 months of conservative treatment. 15
The contractor cites 38 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2021-11-28
- Current revision effective
- 2025-11-20
- Last reviewed by the contractor
- 2025-11-06
- MCD version
- 19
Other related documents: A59138 (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 Palmetto GBA 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 L38737 cover?
PVA (percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP)) is covered in patients who qualify based on the following criteria : 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 L38737 apply to?
Palmetto GBA applies it to Medicare claims in AL, GA, NC, SC, TN, VA, WV. 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 L38737?
The companion billing and coding article A58275 lists 13 ICD-10-CM codes in 2 groups that support medical necessity; the first 13 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L38737?
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.