22838
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
35.10
Facility
$1684.07
Non-Facility
$1684.07
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.
- Aetna considers the following types of braces and casts medically necessary durable medical equipment (DME) for the treatment of scoliosis: Standard thoracolumbosacral orthosis (TLSO).
- 22548 (listed in the table — appears under covered codes)
- Aetna considers surgery (e.g., spinal fusion with instrumentation and bone grafting) for the treatment of idiopathic scoliosis medically necessary for any of the following conditions: Idiopathic scoliosis with curve greater than or equal to 40 degrees in an adolescent younger than age 18;
- Aetna considers surgery (e.g., spinal fusion with instrumentation and bone grafting) for the treatment of idiopathic scoliosis medically necessary for any of the following conditions: Idiopathic scoliosis with curve greater than or equal to 50 degrees in a young adult age 18 to 25.
- Aetna considers growing rods technique medically necessary in the treatment of idiopathic scoliosis for persons who meet criteria for surgery above (includes the MAGEC System).
7 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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