Kyphoplasty is NOT Medically Indicated at This Time
This kyphoplasty request should be denied pending completion of essential diagnostic workup, specifically detailed MRI imaging with STIR/T2 fat-saturation sequences to confirm fracture acuity and rule out alternative pain sources, as the current documentation fails to meet established clinical criteria for vertebral augmentation. 1
Critical Missing Documentation
Inadequate Imaging Assessment
MRI with appropriate sequences is mandatory before proceeding with vertebral augmentation. The Society of Neurointerventional Surgery explicitly states that "MRI should be performed on all patients if not contraindicated as this single test provides comprehensive information" and that "the single most useful sequence is the STIR or T2-weighted sequence with fat saturation: unhealed fractures show a hyperintense signal consistent with bone marrow." 1
The current request lacks detailed imaging reports that would demonstrate bone marrow edema patterns necessary to confirm these are truly acute/subacute fractures rather than chronic fractures. 1
Without proper MRI sequences, it is impossible to determine if the fractures at T12, L1, and L2 are actually the pain generators, as radiographic fracture assessment is not a reliable surrogate measure of symptomatic fracture. 1, 2
Unconfirmed Osteoporosis Diagnosis
There is no documentation of bone mineral density testing (DXA scan) to confirm osteoporosis, which is the presumed underlying etiology. 1
The patient explicitly "denies any knowledge of osteoporosis and has never been treated for osteoporosis" and "does not appear to have any risk factors specific to diminished density." [@clinical documentation]
Without confirmed osteoporosis via DXA or laboratory evidence, the diagnosis of "osteoporotic compression fractures" is presumptive and unsubstantiated. 1
Incomplete Differential Diagnosis Workup
The Society of Neurointerventional Surgery guidelines state that "if there is a clear disparity between the physical examination findings and imaging or a clear alternative source of back pain, vertebral augmentation should not be performed." [@5@]
The documentation does not adequately demonstrate that other causes of pain such as spinal stenosis or herniated intervertebral disk have been ruled out by CT or MRI, as required by the Aetna criteria. [@clinical documentation]
The patient's history of a fall in "middle of 2024" that was "never treated" followed by another fall on 9/13/2025 raises questions about whether all pain is attributable to the recent fractures versus chronic issues. [@clinical documentation]
Procedural Indication Criteria Not Met
Duration of Conservative Therapy
While the patient has been in a TLSO brace for "2-3 months," the Society of Neurointerventional Surgery specifies that failure of medical therapy requires "duration of medical therapy a minimum of 6 weeks" with back pain persisting at a level that prevents ambulation or physical therapy despite appropriate analgesic therapy. [@2@, 1]
The documentation suggests only 1 month since the September 2025 fall, which may be insufficient conservative treatment duration depending on when symptoms became debilitating. [@2@, 1]
Vertebral Body Integrity Assessment
The Aetna criteria require that "the affected vertebra has not been extensively destroyed and is at least 1/3 of its original height with intact posterior cortex." [@clinical documentation]
The clinical note mentions "significant collapse of lumbar one and lumbar two" but without detailed imaging reports, it cannot be verified that vertebral height meets the >1/3 threshold. [@clinical documentation]
Assessment of posterior cortex integrity requires detailed CT or MRI imaging, which has not been provided. 1
Recommended Next Steps Before Approval
Essential Diagnostic Workup
Obtain MRI of thoracic and lumbar spine without and with IV contrast using STIR or T2-weighted sequences with fat saturation to confirm bone marrow edema at T12, L1, and L2, establishing these as acute/subacute rather than chronic fractures. [1, @3@, 1]
Perform DXA scan of lumbar spine and hip to confirm osteoporosis diagnosis and establish baseline bone mineral density for subsequent osteoporosis management. 1
Provide detailed radiology reports documenting vertebral body height measurements (must be >1/3 original height), posterior cortex integrity, degree of canal compromise, and absence of retropulsion or epidural extension. [1, @5@]
Rule out alternative pain sources including spinal stenosis, disc herniation, or other pathology that could explain the patient's symptoms. [@2@, 1]
Clinical Considerations
The patient is only 59 years old with no apparent risk factors for osteoporosis (no tobacco, no steroids, no early menopause, no hysterectomy), making secondary causes of bone fragility more likely and requiring investigation before proceeding. [@clinical documentation]
Consider metabolic workup including serum calcium, phosphate, alkaline phosphatase, 25-OH vitamin D, PTH, and thyroid function to exclude secondary osteoporosis. 1
When Kyphoplasty Would Be Appropriate
If the above workup confirms acute/subacute osteoporotic compression fractures with appropriate imaging characteristics, kyphoplasty would be reasonable after documented failure of 6 weeks of optimal conservative therapy including analgesics, bracing, and physical therapy. 1, 3
The American Heart Association supports kyphoplasty as a reasonable therapeutic option (Class IIA, Level of Evidence B) for severe back pain from vertebral compression fractures refractory to conservative medical therapy, with significant pain reduction achieved earlier than conservative treatment (30 days vs 116 days). 3
However, the evidence base remains limited, and patient selection is critical for optimal outcomes. 1, 2, 3