22837
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
34.61
Facility
$1662.03
Non-Facility
$1662.03
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.
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is performed by either a licensed physician trained in clinical neurophysiology (e.g., a neurologist, physiatrist) or a trained technologist who is practicing within the scope of his/her state license /certification as defined by state law or appropriate authorities and is working under the direct supervision of a physician trained in neurophysiology and i [...]
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is interpreted by a licensed physician trained in clinical neurophysiology, other than the operating surgeon or anesthesiologist, who is either physically in attendance in the operating suite or present by means of a real-time remote mechanism for all electroneurodiagnostic (END) monitoring situations and is immediately available to interpret the recording [...]
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: Monitoring is conducted and interpreted real-time (either on-site or at a remote location) and continuously communicated to the surgical team.
- Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: There is significant risk of brain, spinal cord, cranial nerve, or major peripheral nerve injury during a surgical procedure.
- Monitoring of a cranial nerve during head and/or neck surgery (e.g., resection of skull base tumor, resection of tumor involving a cranial nerve, cavernous sinus tumor, neck dissection, epileptogenic brain tumor/tissue resection).
6 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
CIGNA-0509 — Intraoperative Monitoring - (0509)
Related Codes
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