0790T — Revj rplcmt/rmvl vrt tethrg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- VBT is intended for individuals who are skeletally immature, with a major cobb angle of 30 to 65°, and who have failed and/or are intolerant to bracing. (policy Description of Services)
- FDA HDE indication (The Tether): 'indicated for skeletally immature patients that require surgical treatment to obtain and maintain correction of progressive idiopathic scoliosis, with a major Cobb angle of 30 to 65° whose osseous structure is dimensionally adequate to accommodate screw fixation, as determined by radiographic imaging. Patients should have failed bracing and/or be intolerant to brace wear.' (policy U.S. Food and Drug Administration section)
- Radiographic imaging demonstrating 'osseous structure dimensionally adequate to accommodate screw fixation, as determined by radiographic imaging.' (FDA HDE text quoted in policy)
Key Coverage Criteria
- None — Vertebral body tethering for the treatment of scoliosis is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.
4 Active Policies
UHC-POL-vertebral-body-tethering-scoliosis — Vertebral Body Tethering for Scoliosis
UMR-POL-UMR-vertebral-body-tethering-scoliosis — Vertebral Body Tethering for Scoliosis
SUREST-POL-SUREST-vertebral-body-tethering-scoliosis — Vertebral Body Tethering for Scoliosis
REGENCE-SUR232 — Vertebral Body Tethering and Stapling
Related Codes
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