Kyphoplasty denied for failing step therapy by Medicare?

Medicare's specific coverage criteria for kyphoplasty are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Medicare Denied This Claim: Step Therapy Not Completed

Medicare's Local Coverage Determinations (LCDs) for vertebral augmentation typically require documentation that conservative, non-surgical treatments were attempted and failed before kyphoplasty is considered medically necessary. A step-therapy denial means the contractor determined there is insufficient evidence in the record that the required prior treatments were tried, for an adequate duration, and documented to have been ineffective. This is one of the most common — and most successfully reversed — denial types, because the information needed to rebut it is usually already in the patient's chart.

## Your Federal Appeal Rights

Medicare's structured five-level process applies:

• Level 1 — Redetermination with the MAC: file within 120 days of the denial.
• Level 2 — Reconsideration with the QIC: file within 180 days of the redetermination.
• Levels 3–5 — ALJ Hearing, Medicare Appeals Council, Federal District Court.
• Expedited review when standard timelines would jeopardize health.

Deadlines are printed on your MSN or EOB. Missing a deadline can forfeit your right to that appeal level, so act promptly.

## Why Step-Therapy Denials Are Frequently Reversed

Conservative care is often documented across multiple providers, clinics, and settings — primary care, physical therapy, pain management, emergency visits. Contractors sometimes deny because the claim file does not consolidate this history clearly, not because it does not exist. The fix is assembling a complete, chronological record and submitting it as a unified exhibit.

## Documentation to Gather

1. Comprehensive prior-treatment log — a chronological table listing each conservative treatment tried, the treating provider, start and end dates, and the documented reason it was discontinued or deemed insufficient. Include all relevant categories specified in the applicable LCD (commonly: analgesic therapy, bracing, and physical or rehabilitation therapy — verify the exact requirements in the current LCD). 2. Chart notes from all treating providers — office notes, physical therapy discharge summaries, pain management records, and emergency department visits that document pain severity and functional decline despite treatment. 3. Imaging confirming acute fracture — CT or MRI with date, level, and acuity notation. 4. Prescriber medical-necessity letter — a narrative from the treating surgeon summarizing the full conservative-care history, explaining why each modality failed, and confirming that the patient's clinical status met the LCD's step-therapy requirements prior to proceeding to surgery. 5. Applicable LCD — download the current version from the MAC's website. Identify the exact step-therapy requirements and map each one to a specific chart entry.

## Criteria-Mapping Structure

| LCD Step-Therapy Requirement | Chart Evidence | |---|---| | Analgesic therapy attempted | Pharmacy records, prescriptions, chart notes | | Bracing or orthotic support | Prescription, physical therapy notes, duration | | Rehabilitation or physical therapy | PT discharge summary, dates, documented outcomes | | Duration of conservative care (per LCD) | Date of fracture vs. date of procedure | | Failure documented in the record | Chart notes describing ongoing pain/disability |

Present this table as a cover exhibit to your appeal. It makes the reviewer's job straightforward and significantly improves reversal rates.