Application for funding:
Percutaneous vertebroplasty
Instructions for completion of form
Please complete all sections of this form. We would appreciate it if the information you provide is typed and not
handwritten. Without the information requested, assessment and authorisation for funding may be delayed.
Bupa only funds treatment that is covered under the member’s policy and that is in line with published evidencebased guidelines and we use these to assess eligibility for funding. You will receive a response about eligibility
for Bupa funding within 48 hours.
If you have any questions please contact the Bupa Back Care Team by phone: 0845 600 8277†.
Please return the completed form to the Bupa Back Care Team by fax: 0161 254 5808
Please do not use email to send patient-identifiable data as it is not necessarily a secure method of
communication.
Member’s name:
Member’s date of birth (DD/MM/YYYY):
Member’s address:
Bupa registration number:
Proposed date of procedure:
Consultant’s name:
Bupa Provider Number:
Name of hospital:
Procedure
Please indicate which procedure is proposed:
Percutaneous vertebroplasty for vertebral fracture caused by vertebral metastases
Percutaneous vertebroplasty for unhealed osteoporotic vertebral compression fracture (where the patient’s
pain is severe and ongoing despite optimal pain management)
Eligibility criteria
Bupa will consider funding percutaneous vertebroplasty for vertebral fractures caused by vertebral metastases
where there is no evidence of metastatic spinal cord compression or spinal instability and in accordance with all
criteria in NICE clinical guideline CG75.
Bupa will consider funding percutaneous vertebroplasty for unhealed osteoporotic vertebral compression
fractures where the patient’s pain is severe and ongoing despite optimal pain management, where it has been
confirmed to be at the level of the fracture by physical examination and MRI (as per NICE technology appraisal
guidance TA279), and where the patient meets all of the following eligibility criteria (as per VERTOS II trial,
www.ncbi.nlm.nih.gov/pmc/articles/PMC2169262/pdf/1745-6215-8-33.pdf) –
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the patient is aged 50 years or older;
Application for funding: Percutaneous
vertebroplasty
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vertebral compression fracture has been diagnosed on spinal radiograph with a minimum of 15% loss of
height;
the level of fracture is Th5 or lower;
the patient has had back pain for 6 weeks or less;
there is a visual analogue score of 5 or more (where 0 is no pain and 10 is worst pain ever);
bone oedema of vertebral fracture diagnosed on MRI;
there is focal tenderness at the fracture level; and
the patient has a confirmed decreased bone density (T-score ≤ -1)
Benefit will not usually be considered where any of the following are present:
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severe cardiopulmonary comorbidity
untreatable coagulopathy
systemic or local spine infection
suspected underlying malignant disease
radicular syndrome
spinal-cord compression syndrome
contraindication for MRI
Where there is clinical evidence to support the use of this treatment outside the above guidelines, consultants
are requested to call the Back Care Support Policy Operations team on 0845 600 8277* so that we can review
this request.
Declaration
To be completed by the consultant
Please sign below to confirm that the procedure for which funding is sought meets the eligibility criteria. In order
to confirm eligibility for funding, Bupa may verify the information submitted in this form with a copy of the
patient’s full medical notes, which may be requested from you and the patient’s GP.
Signed:
Date:
Please print name:
†Lines
are open 8am to 8pm, Monday to Friday and 8am to 1pm Saturday. Calls may be recorded and may be monitored.
June 2013
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