May 05, 2023

ACR Supports the Alignment of Medicare Coverage Policy with Commercial Payers for PVA

The American College of Radiology® (ACR®) joined other medical specialty societies whose members utilize and/or perform interventional spine procedures in submitting a letter to six commercial insurance payers, asking them to change medical necessity language contained in their coverage policies for Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture.

The societies urged Aetna, Aim Specialty Health, Cohere Health, Evicore, Health Care Services Corporation and Humana to align their plans with Medicare coverage policies on this clinical topic. Research shows at least six commercial payers require four to six weeks of conservative management before treatment for the vertebral compression fracture (VCF). This is inconsistent with current literature and Medicare coverage policies in effect since 2021. The societies contend limiting surgical procedures to fractures more than six weeks old should be revised/eliminated, as this requirement has the potential to negatively impact patient outcomes and providers’ ability to deliver evidence-based, appropriate spinal care to all patients.

At least one payer, AIM Specialty Health, has responded to the letter and is reviewing the issue.

For questions about Medicare Coverage processes, contact Alicia Blakey, ACR Principal Economic Policy Analyst.