CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Interventions for Progressive Scoliosis

Defines coverage and medical necessity for vertebral body stapling and vertebral body tethering as fusionless surgical interventions for progressive juvenile/adolescent idiopathic scoliosis for Blue Cross Blue Shield - Rhode Island commercial and Medicare Advantage plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Interventions for Progressive Scoliosis

Policy CodePolicy N/A

Change TypeClarified coding (new CPT codes listed as not covered)

Effective DateJan 1, 2024

Next Review Date

Key ActionRefer to the member's Evidence of Coverage or Subscriber Agreement for benefits and contact the provider call center for member-specific benefits; claims for listed tethering/stapling codes may be denied as not covered/not medically necessary.

SourceLink

POLICY UPDATE CHANGES

New CPT codes for vertebral body tethering effective 1/01/2024 are listed as not covered/not medically necessary.

2Surgical interventions listed (stapling, tethering)

4CPT codes listed as not covered

2024-01Policy effective month

Coverage Summary

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This policy addresses coverage and medical necessity for vertebral body stapling and vertebral body tethering, fusionless surgical interventions proposed as alternatives to bracing for progressive juvenile and adolescent idiopathic scoliosis. The policy position is Not Covered / Not Medically Necessary (not_covered_cosmetic) for both Medicare Advantage and Commercial Products. Effective date: 2024-01-01.

Key Policy Facts

Effective Date01/01/2024

Last Review12/20/2023

Policy StatusCURRENT — Not covered / Not medically necessary for Medicare Advantage and Commercial Products

Scope SummaryDefines coverage and medical necessity for vertebral body stapling and vertebral body tethering as fusionless surgical interventions for progressive juvenile/adolescent idiopathic scoliosis for Blue Cross Blue Shield - Rhode Island commercial and Medicare Advantage plans.

Evidence highlights include a meta-analysis of vertebral body tethering studies with >36 months follow-up reporting 74% clinical success, a 52% complication rate, and a 16% unplanned reoperation rate. Overall evidence quality is limited—predominantly case series, small single-center studies, and uncontrolled cohorts—insufficient to determine an improvement in net health outcome.

Medical-Necessity / Policy Statements

Policy Statement - Medicare Advantage Plans

Vertebral body stapling and vertebral body tethering are covered only when evidence demonstrates improvement; current policy states not covered:

Vertebral body stapling and vertebral body tethering for the treatment of scoliosis are not covered for Medicare Advantage Plans as the evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

Policy Statement - Commercial Products

Commercial product coverage position:

Vertebral body stapling and vertebral body tethering for the treatment of scoliosis are not medically necessary for Commercial Products as the evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

Not Covered / Not Medically Necessary

Vertebral body stapling and vertebral body tethering are not covered for Medicare Advantage and are not medically necessary for Commercial Products because the available evidence is insufficient to demonstrate improvement in net health outcomes. Reported complication and reoperation rates (including tether breakage, pulmonary complications, and overcorrection) and the predominance of small, uncontrolled studies support the decision to deny coverage.

Denial Risk

Potential Denial for Non-Covered Procedure

Claims for the listed CPT codes may be denied as not covered/not medically necessary for Medicare Advantage and Commercial Products.

22836
22837
22838
0790T

Coding

Not covered / Not medically necessary codes (Medicare Advantage and Commercial)CPTNot Covered

22836	Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; Up to 7 vertebral segments (New code effective 1/01/2024)
22837	Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; 8 or more vertebral segments (New code effective 1/01/2024)
22838	Revision (eg, augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed (New code effective 1/01/2024)
0790T	Revision (eg, augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed (New code effective 1/01/2024)

Not covered / Not medically necessary codes (Medicare Advantage and Commercial)CPTNot Covered

22836	Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; Up to 7 vertebral segments (New code effective 1/01/2024)
22837	Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; 8 or more vertebral segments (New code effective 1/01/2024)
22838	Revision (eg, augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed (New code effective 1/01/2024)
0790T	Revision (eg, augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed (New code effective 1/01/2024)

Material change: New CPT codes for vertebral body tethering effective 1/01/2024 are listed as not covered/not medically necessary (codes 22836, 22837, 22838, 0790T).

This change is marked as material.

Provider Actions & Operational Notes

Prior Authorization

Not applicable — Policy indicates 'Not applicable' under Prior Authorization; no prior authorization requirement is specified in the policy text for these procedures.

Documentation Required

Benefit Determination

Benefits may vary by contract. Providers should refer to the member's Evidence of Coverage or Subscriber Agreement for applicable benefits and eligibility and contact the provider call center for member-specific benefits.

Denial Risk

Potential Denial for Non-Covered Procedure

Claims for the listed CPT codes may be denied as not covered/not medically necessary for Medicare Advantage and Commercial Products per this policy.

22836
22837
22838
0790T

Background, Evidence, and Definitions

Vertebral body stapling and tethering are fusionless surgical techniques developed as alternatives to traditional orthotic bracing for juvenile and adolescent idiopathic scoliosis patients at high risk of curve progression. Stapling uses memory-shape staples applied to vertebral growth plates, while tethering uses an anteriorly placed flexible tether to modulate growth and correct thoracic curves.

The clinical evidence is limited: available studies are mainly case series, small single-center reports, and a few cohort data with small sample sizes and limited follow-up. Reported outcomes include promising Cobb angle corrections but also notable complication and reoperation rates; additional larger, longer-term, controlled studies are needed to adequately evaluate safety and efficacy.

Metric	Summary
Clinical success
74% clinical success reported in a meta-analysis of vertebral body tethering studies with >36 months follow-up
Complication rate
52% complication rate reported in the same meta-analysis (most common: tether breakages, pulmonary complications, overcorrections)
Unplanned reoperation rate
16% unplanned reoperation rate reported in the meta-analysis of tethering studies with >36 months follow-up
Key evidence quality
Predominantly case series, small single-center studies, uncontrolled cohorts; evidence insufficient to determine improvement in net health outcomes

Risser sign: Describes the level of ossification of the iliac apophysis (0 to 5) used to assess skeletal maturity and remaining spinal growth.

Cobb angle: Radiographic measure of spinal curve magnitude used to diagnose and assess scoliosis.

Revision History

2024-01-01coding_changeLatest

New CPT codes 22836, 22837, 22838, and 0790T effective 1/01/2024 are listed as not covered / not medically necessary.

2023-12-20review

Policy last reviewed.

2024-01-01effective_date

Policy effective date.

2023-12-20policy_statement

Vertebral body stapling and vertebral body tethering are not covered for Medicare Advantage Plans due to insufficient evidence to demonstrate improvement in net health outcomes.