CurrentCapital BluecrossPolicy MP 1.120

Interventions for Progressive Scoliosis

Defines medical necessity criteria for orthotic bracing and states investigational stance for fusionless surgical growth modulation (vertebral body stapling and tethering) for juvenile and adolescent idiopathic scoliosis; applies to Capital BlueCross products with noted product variations.

Policy Summary

PayerCapital Bluecross

PolicyInterventions for Progressive Scoliosis

Policy CodePolicy MP 1.120

Change TypeAdministrative — no material clinical changes

Effective DateOct 1, 2025

Next Review Date

Key ActionDocument Cobb angle, Risser grade (or post‑menarche timing), and evidence of curve progression and remaining growth when requesting bracing coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

25°-40°Cobb angle range for primary brace eligibility

Risser 0-3Skeletal maturity range for brace eligibility

>20° + progressionAlternate brace eligibility

≥45°Fusion commonly considered at

18-23 hrs/day

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Typical full-time brace wear

74%VBT reported success (meta-analysis)

Coverage Criteria for Bracing and Growth-Modulation Procedures

Medical necessity criteria for rigid orthosis

Covered when ONE of the following is met:

Primary brace criteria: Idiopathic spinal curve angle between 25° and 40° AND spinal growth has not been completed (Risser grade 0-3; no more than 1-year postmenarche)25°-40°; Risser 0-3

Alternate brace criteria: Idiopathic spinal curve angle greater than 20° AND documented increase in the curve angle AND at least 2 years growth remain (Risser grade 0 or 1; pre-menarche)>20° with progression; ≥2 years growth remaining

Conventional rigid bracing — covered when medically necessary

Covered when ALL of the following are met

Bracing coverage criteria: Patient has juvenile or adolescent idiopathic scoliosis at high risk of progressionHigh risk defined as Cobb angle ≥25° with remaining spinal growth, or progressive 20° with ≥2 years growth remaining

Conventional rigid bracing (full-time or nighttime rigid) has evidence to reduce progression and need for fusion; supported by high-quality trials including the 2013 NIH-sponsored trial.

Investigational interventions

Not covered / investigational:

Non‑criteria orthosis use: Use of an orthosis for scoliosis that does not meet the specified bracing criteria (Cobb angle and skeletal maturity/growth remaining)

Considered investigational due to insufficient evidence of net health benefit.

Vertebral body stapling and tethering: Vertebral body stapling and vertebral body tethering for the treatment of scoliosis

Considered investigational; insufficient evidence to conclude improvement in health outcomes; investigational coding noted (e.g., 22899) and not covered when reported for these procedures.

Alternative brace types — insufficient evidence

Microcomputer‑controlled brace: Evidence limited to a pilot randomized trial (small sample) showing possible benefit but insufficient data to determine net health outcome

Insufficient evidence to establish superiority or net health benefit; not established as standard of care.

Flexible brace: Randomized and comparative studies did not demonstrate equivalent outcomes to conventional rigid bracing; evidence insufficient to conclude improvement in net health outcome

Insufficient evidence to support as alternative to conventional rigid bracing.

Growth-modulation surgical procedures — insufficient / investigational

Vertebral body stapling: Limited evidence (comparative cohort, case-control, and case series); may control some thoracic curves 20°–35° but less effective than bracing for larger curves

Evidence insufficient to determine improvement in net health outcome; additional larger, long-term studies needed.

Vertebral body tethering: Evidence limited to case series and meta-analyses of case series reporting clinical success but high complication and reoperation rates (meta-analysis: 74% success, 52% complications, 16% unplanned reoperation)

Insufficient evidence; considered investigational and not covered per coding section.

This policy segment does not address conventional spinal fusion surgery for scoliosis. Conventional surgery for scoliosis is typically considered for individuals with curve angles measuring 45° or more, and those cases fall outside the scope of the bracing and fusionless growth‑modulation coverage decisions described here.

Vertebral body stapling and vertebral body tethering are identified in this policy as investigational modalities for the treatment of scoliosis and are therefore not covered when used for that indication. The coding section lists these procedures as investigational and not covered (e.g., reporting with unlisted procedure code 22899 for these techniques).

Published studies and reviews cited in the policy raise caution about patient selection and technical limits for vertebral body stapling and tethering. Reports note the techniques have been evaluated primarily in small case series or single-center cohorts and that stapling may control some thoracic curves of approximately 20°–35° while being less effective for larger curves. Other referenced papers specifically discuss cautions and patient selection criteria for stapling, and tethering reports highlight complications such as tether breakage, pulmonary events, and overcorrection.

The policy states vertebral body stapling and vertebral body tethering remain investigational because available evidence is limited and methodologically constrained. For tethering, evidence is largely case series and one meta-analysis of such series; for stapling the evidence includes comparative cohort and case‑control studies but sample sizes are small and follow‑up is limited. These limitations prevent a conclusion that these procedures improve net health outcomes compared with standard therapy.

Accordingly, vertebral body stapling and vertebral body tethering are considered investigational/insufficient evidence for the treatment of scoliosis and are designated as not medically necessary under this policy segment. Billing for these procedures for scoliosis treatment therefore carries a risk of denial.

This coverage segment does not present explicit, separate not‑medically‑necessary (NMN) conditional statements beyond the investigational designation, but the referenced literature and cited reviews include discussions of cautions, patient selection limits, and outcome uncertainties for vertebral body stapling and tethering that underpin the investigational stance.

Coding and Billing Tables

Covered HCPCS/L Codes (orthoses/brace)HCPCSCovered

L0700	Procedure Codes group start (per policy listing)
L0710	Specific L-code listed as covered when medically necessary
L0720	Specific L-code listed as covered when medically necessary
L1000	Specific L-code listed as covered when medically necessary
L1005	Specific L-code listed as covered when medically necessary
L1006	Specific L-code listed as covered when medically necessary
L1007	Specific L-code listed as covered when medically necessary
L1010	Specific L-code listed as covered when medically necessary
L1020	Specific L-code listed as covered when medically necessary
L1025	Specific L-code listed as covered when medically necessary

1–10 of 34

1/4

Devices with FDA HDEmixed

H190005	FDA HDE number for The Tether™ (Zimmer Biomet Spine)
H210002	FDA HDE number for REFLECT™ Scoliosis Correction System

Investigational / Not Covered CPT Codes (used to report vertebral body stapling or tethering)CPTNot Covered

22899

Unlisted procedure, spine (used to report vertebral body stapling or tethering in investigational context as listed)

Relevant ICD-10 Diagnosis CodesICD-10

M41.112	Juvenile idiopathic scoliosis; cervical region
M41.113	Juvenile idiopathic scoliosis; cervicothoracic region
M41.114	Juvenile idiopathic scoliosis; thoracic region
M41.115	Juvenile idiopathic scoliosis; thoracolumbar region
M41.116	Juvenile idiopathic scoliosis; lumbar region
M41.117	Juvenile idiopathic scoliosis; lumbosacral region
M41.119	Juvenile idiopathic scoliosis, site unspecified
M41.122	Adolescent idiopathic scoliosis, cervical region
M41.123	Adolescent idiopathic scoliosis, cervicothoracic region
M41.124	Adolescent idiopathic scoliosis, thoracic region

1–10 of 15

1/2

Historically managed CPT / Temp codesCPT

0656T	Previously added procedure code (historical entry)
0657T	Previously added procedure code (historical entry)

Active HCPCS/L Codes noted in policy historyHCPCS

L1006	HCPCS/L code added to policy effective 10/01/2024
L0720	HCPCS/L code added to policy effective 04/01/2025
L1007	HCPCS/L code added to policy effective 10/01/2025

Cobb angle — primary and alternative thresholds

Primary Cobb angle thresholdIdiopathic spinal curve angle between 25° and 40° (eligible for conventional rigid bracing)

Alternative lower threshold with progressionCurve greater than 20° with documented increase in curve angle plus at least 2 years growth remaining

High-risk definition for progressionCurves measuring ≥25° with remaining spinal growth are considered high risk

Risser grade — eligibility and growth note

Eligible Risser range for bracingRisser grade 0–3 (spinal growth not completed); no more than 1 year post-menarche

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required for Device-Based Procedures

Prior authorization is required for device-based surgical procedures (e.g., vertebral body tethering systems with FDA Humanitarian Device Exemption (HDE) status and other implantable devices) prior to scheduling. Providers should submit complete clinical documentation to support medical necessity and device use.

Obtain prior authorization for procedures involving implantable devices (including HDE devices) before performing surgery.
Use current procedure and HCPCS/L coding when requesting authorization; policy history documents addition/removal of codes (e.g., 0656T/0657T, L1006, L0720, L1007) — ensure the codes submitted are effective for the date of service.

Billing Rule

Prior Authorization and Coding Implications

Prior authorization review will include an administrative and coding review. Providers must use up-to-date procedure codes when requesting authorization or submitting claims. Historical code changes have occurred and may affect adjudication.

Background and Evidence Summary

Adolescent idiopathic scoliosis (AIS) is an abnormal lateral and rotational curvature of the spine that typically presents after age 10 and may progress during the rapid growth of puberty. Curve magnitude is measured by the Cobb angle, and skeletal maturity is estimated by the Risser sign. Rapid growth increases the risk of progression; conventional bracing is aimed at patients who have not completed growth (commonly Risser 0–3) and is generally recommended for curves in the approximate range of 25°–40° to reduce progression and the subsequent need for fusion. Fusion surgery is usually considered for curves that progress to about 45° or more.

The policy cites evidence summaries and case series that emphasize limitations in current data for stapling and tethering: small sample sizes, single‑center series, lack of control groups, variable follow‑up, and notable complication and reoperation rates reported in meta‑analyses. These evidence limitations lead to recommendations for careful patient selection in study reports and for additional larger, longer‑term comparative studies before these techniques can be judged equivalent or superior to standard bracing.

Definitions and Key Terms

Cobb angle — definition

DefinitionCobb angle: the angle formed between intersecting lines drawn perpendicular to the top and bottom vertebrae of the curve on radiograph (measures curve magnitude)

UsePrimary radiographic measure to quantify scoliosis curve magnitude and determine progression risk

Clinical relevanceThresholds based on Cobb angle guide bracing (eg, 25°–40°) and consideration for surgery (eg, ≥45°)

Risser sign — definition and grading (0–5)

Definition and gradingRisser sign: amount of calcification of the iliac apophysis measuring remaining spinal growth; graded 0 (no ossification) through 5 (full ossification)

Grade rangeGrades 0–5, where 0–1 = 0%–25% ossification (immature) and 5 = 100% ossification (mature)

Policy Revision and Coding History

2025-09-09Administrative update - codingLatest

New HCPCS/L code L1007 added to the policy effective 2025-10-01.

2025-08-28Administrative update

Removed Benefit Variations section and updated Disclaimer.

2025-04-09Consensus review

Policy Summary

PayerCapital Bluecross

PolicyInterventions for Progressive Scoliosis

Policy CodePolicy MP 1.120

Change TypeAdministrative — no material clinical changes

Effective DateOct 1, 2025

Next Review Date

Key ActionDocument Cobb angle, Risser grade (or post‑menarche timing), and evidence of curve progression and remaining growth when requesting bracing coverage.

SourceLink

On This Page

Risser 0–1 implicationRisser grade 0 or 1 corresponds to 0%–25% iliac apophysis ossification and indicates substantial remaining growth (≈≥2 years in many patients)

Mature Risser gradeRisser grade 5 indicates full ossification and no remaining spinal growth (not eligible based on growth criteria)

Cobb angle threshold for high risk (bracing indication)

Bracing indication — high risk thresholdCurve ≥25° when spinal growth remains (indication for conventional bracing)

Progressive-curve alternative indicationProgressive 20° curve with at least 2 years of growth remaining (eligible for bracing)

Contextual evidenceNIH-sponsored 2013 trial and systematic reviews support bracing for curves meeting these thresholds

Verify coding for fusionless procedures (e.g., vertebral body stapling/tethering) — miscellaneous codes such as 22899 have been used historically; check current coding guidance.
Expect administrative/coding review of requests and claims; prior additions/removals of CPT/HCPCS/L codes are documented in policy history and may impact authorization and claims processing.

Denial Risk

Denial Risk for Bracing That Does Not Meet Criteria

Use of an orthosis that does not meet the policy-specified bracing criteria risks denial. Document objective clinical measures to demonstrate that bracing meets medical necessity criteria.

Bracing that does not meet specified criteria (Cobb angle, Risser grade/menarche status, documented progression, remaining growth) may be considered investigational and denied.
Ensure the medical record includes Cobb angle, Risser grade or post-menarche timing, evidence of progression, and estimate of remaining growth to reduce denial risk.

Denial Risk

Investigational Procedures Not Covered

Vertebral body stapling and vertebral body tethering are considered investigational and are not covered. Claims for these procedures may be denied as not medically necessary when used for treatment of scoliosis.

Vertebral body stapling/tethering (including use of devices cleared for other indications or used off-label for scoliosis) is investigational and not covered.
Providers should not assume coverage for stapling/tethering; prior authorization does not guarantee payment when a procedure is investigational.

Documentation Required

Coverage and Documentation Note

Coverage determinations depend on the member's benefit program, medical necessity, and supporting documentation. Administrative determinations and final claim payment are subject to contract terms and eligibility on the date of service.

Final coverage and payment depend on the member's benefit plan, eligibility on date of service, and documentation demonstrating medical necessity.
Contact Capital Blue Cross Provider Services for questions about benefit-specific coverage or authorization requirements.

Step Therapy

Step Therapy Preference: Bracing Before Fusionless Procedures

Bracing is the preferred initial therapy (step therapy) for skeletally immature patients at high risk of progression. Fusionless surgical options should be considered only after recommended conservative measures have been attempted and documented.

Conservative treatment (rigid bracing meeting policy criteria) is expected before considering investigational fusionless procedures.
Document failure of, intolerance to, or contraindication for bracing when proposing alternatives such as tethering (note: tethering is investigational and not covered).

Note

Stepwise Approach — Conservative Treatment First

Apply a stepwise approach: conservative management first (appropriate bracing and follow-up), then re-evaluate for progression before considering surgical interventions. Ensure all conservative treatments and objective progression evidence are in the record.

Conservative treatment and documented progression are required elements before escalation of care; bracing is the standard initial intervention for high-risk curves.
For authorization of advanced interventions, include prior treatment history, brace wear compliance (if available), serial Cobb angles, growth assessment (Risser/menarche), and rationale for surgery.

Clinical useUsed to estimate remaining growth to guide bracing eligibility and timing of interventions

Risser sign — growth implications by grade

Growth implication by Risser gradeRisser 0–1 indicates substantial remaining growth (0%–25% ossification) often corresponding to ≥2 years of growth; increasing Risser grades reflect decreasing remaining growth

Clinical interpretationRisser grades 0–3 used to define patients who have not completed growth for bracing eligibility; grade 5 indicates skeletal maturity

Temporal noteChildren may progress from Risser 1 to Risser 5 over a brief period (e.g., ~2 years), so timing influences decision-making

510(k) — FDA premarketing submission

510(k) purposeA 510(k) is a premarket submission to the FDA demonstrating that a device is substantially equivalent to a legally marketed device not subject to PMA

Comparison requirementApplicants must compare their device to one or more similar marketed devices and support substantial equivalence claims

Regulatory context510(k) is distinct from PMA and is used for many orthopedic devices referenced in device regulatory summaries

Vertebral body tethering (VBT) — definition

DefinitionVertebral body tethering (VBT) is a fusionless anterior growth-modulation surgical technique that uses an implanted tether to modulate vertebral growth in skeletally immature patients with idiopathic scoliosis

Intended effectAims to harness remaining growth to correct curvature without fusion by applying tension on the convex side of the curve

Evidence contextDiscussed in case series and FDA summaries; outcomes include reported success and notable complication and reoperation rates in meta-analyses

Vertebral body stapling (VBS) — definition

DefinitionVertebral body stapling (VBS) is a fusionless growth-modulation technique that places staples across vertebral growth plates to modulate growth in growing children with moderate idiopathic scoliosis

Intended useDesigned to control curve progression in patients with moderate curves (often 20°–35°) while preserving spinal motion by avoiding fusion

Evidence and cautionsLimited evidence from cohort and case series; patient selection and longer-term outcomes remain uncertain and are described in cited studies

Consensus review with no change to policy statement; references updated and coding reviewed.

2025-03-12Administrative update - coding

New HCPCS/L code L0720 added to the policy effective 2025-04-01.

2024-09-18Administrative update - coding

New HCPCS/L code L1006 added to the policy effective 2024-10-01.

2023-06-16Consensus review

Consensus review with no change to the policy statement; references, background and rationale updated and coding reviewed.

2022-06-03Consensus review - coding change

Procedure codes 0656T and 0657T removed from the policy (managed by third party); references updated and coding reviewed.

2021-06-14Administrative update - coding

New procedure codes 0656T and 0657T were added to the policy.

2020-05-12Consensus review

Consensus review with product variation, background, and references updated; coding reviewed.

Billing Rule

Coding update implication — HCPCS/L code additions noted in policy history

Policy history lists specific HCPCS/L code additions with effective dates; providers must bill using the current HCPCS/L codes listed in the policy for services provided on or after those effective dates.

Refer to policy history for L1006 (effective 10/01/2024), L0720 (effective 04/01/2025), and L1007 (effective 10/01/2025).