Currentharvard pilgrim health carePolicy N/A

Anterior Vertebral Body Tethering

Defines medical necessity criteria, limitations, and prior authorization requirement status for anterior vertebral body tethering (AVBT) for idiopathic scoliosis in skeletally immature patients across Harvard Pilgrim/Tufts products. Lists CPT/HCPCS codes requiring prior authorization and describes provider/facility qualifications.

Policy Summary

Payerharvard pilgrim health care

PolicyAnterior Vertebral Body Tethering

Policy CodePolicy N/A

Change TypeAdministrative updates; prior CPT code additions

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit supporting clinical documentation pertinent to the service request when prior authorization is required; the policy lists specific CPT/HCPCS codes that require authorization.

SourceLink

POLICY UPDATE CHANGES

November 19, 2025: Reviewed by MPAC for annual review, renewed without changes effective January 1, 2026

November 2023: coding updated per AMA CPT; codes 22836 and 22837 added effective January 1, 2024

1Covered Indication (Idiopathic thoracic/lumbar AIS)

8Limitations / Exclusions listed

4Radiographic thresholds specified

Coverage Summary

Anterior Vertebral Body Tethering (AVBT) is a non-fusion surgical option for adolescent idiopathic scoliosis that uses anchors/vertebral body screws placed on the convex side of the curve and a polymer tensioning tether to partially correct curvature and continue correction as the patient grows. The Tether™ Vertebral Body Tethering System received FDA approval in April 2019 for select skeletally immature patients with progressive AIS.

This policy defines medical necessity criteria, limitations, and prior authorization requirements for AVBT for idiopathic thoracic and/or lumbar adolescent scoliosis across Harvard Pilgrim and Tufts Health Plan products (including applicable commercial and public plan products). For dual-eligible members, the Plan uses CMS and MassHealth guidance where applicable; when CMS/MassHealth do not provide guidance, the Plan's internally developed medical necessity guidelines are used.

Medical-Necessity Criteria — Anterior Vertebral Body Tethering

Medical Necessity Criteria - Anterior Vertebral Body Tethering

The Plan considers anterior vertebral body tethering as medically necessary when documentation confirms ALL of the following:

ALL of the following

Idiopathic scoliosis of thoracic and/or lumbar spine
ALL of the following
- Major Cobb angle of 35 to 65 degrees and osseous structure is dimensionally adequate to accommodate screw fixationCobb angle 35-65 degrees
- Cobb angle decreases in magnitude below 30 degrees on bending filmsCobb angle < 30 degrees on bending films
ALL of the following
- ONE of
  - Failed external bracing defined as curvature progression greater than 5 degrees despite external brace wearprogression > 5 degrees despite brace
  - External bracing is not/no longer indicated secondary to skeletal maturity or severe scoliosis (greater than 45 degrees)Cobb angle > 45 degrees may make bracing not indicated
  - Documentation of intolerance to external brace wear as prescribed despite reasonable efforts to improve brace fit, comfort, and brace wear compliance
ALL of the following
- ONE of
  - Risser grade 0-2Risser grade 0-2
  - Sanders Skeletal Maturation Stage (SMS) less than 5SMS < 5
Tethering device must be FDA approved
Qualified orthopedic/spine specialist trained and with experience in AVBT technique has completed in-person evaluation and has documented member's suitability for AVBT and the rationale for AVBT procedure
Procedure will be performed by qualified orthopedic/spine specialist trained and with experience in AVBT technique at a facility with appropriate experience and expertise in AVBT procedure

Limitations / Not Covered

The Plan will not cover AVBT for the following:

ANY of the following

Skeletal maturity achieved with no spinal growth remaining
Congenital scoliosis
Hyperkyphosis (40-50 degrees)
Kyphosis in the lumbar spine or at the thoracolumbar junction
Vertebral or chest wall deformity malformation in addition to scoliosis (e.g., pectus excavatum, severe rib prominence defined as trunk rotation greater than 20 degrees as measured by scoliometer)trunk rotation > 20 degrees by scoliometer
Previous surgery at the spinal levels where scoliotic curve(s) exist, unless related to prior tether correction
Member is non-ambulatory
Altered muscle function as a result of progressive neuromuscular disease

Coding

CPT/HCPCS codes requiring prior authorizationmixedCovered

22836	Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; up to 7 vertebral segments.
22837	Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; up to 8 vertebral segments.
0656T	Vertebral body tethering, anterior; up to 7 vertebral segments.
0657T	Vertebral body tethering, anterior; up to 8 or more vertebral segments.

Provider Actions

Prior Authorization

Prior authorization required for listed CPT/HCPCS codes

Affected CPT/HCPCS codes: 22836, 22837, 0656T, 0657T. Submit supporting clinical documentation pertinent to the service request when prior authorization is required (include imaging, clinical measurements, skeletal maturity staging, documentation of failed or intolerance to bracing, device FDA approval, and specialist evaluation).

Codes requiring prior authorization: 22836, 22837, 0656T, 0657T
Include supporting clinical documentation with prior authorization request

Documentation Required

Document clinical criteria and specialist evaluation

Provide documentation of radiographic imaging confirming major Cobb angle and bending film results; documentation of skeletal maturity staging (Risser grade or Sanders SMS); evidence of failed external bracing or documented intolerance to bracing; confirmation that the tethering device is FDA approved; and documentation of an in-person specialist evaluation by a qualified orthopedic/spine specialist stating suitability and rationale for AVBT.

Radiographic imaging: major Cobb angle (35–65°) and bending films showing Cobb < 30°
Skeletal maturity staging: Risser grade 0–2 or Sanders SMS < 5
Evidence of failed bracing (progression > 5° despite brace) or documented intolerance to bracing
Device must be FDA approved
In-person specialist evaluation documenting suitability and rationale for AVBT

Documentation Required

Facility and surgeon qualifications

Document that the procedure will be performed by a qualified orthopedic/spine specialist trained and experienced in the AVBT technique and that the facility has appropriate experience and expertise; include documentation of the surgeon's and facility's training and AVBT experience.

Surgeon: training and experience in AVBT documented
Facility: appropriate experience and expertise in AVBT procedure documented

Background & Evidence

AVBT involves placement of vertebral body screws/anchors and a synthetic polymer tensioning cord along the convex side of the spinal curve to modulate growth and partially straighten the spine. The Tethering System was granted FDA approval in April 2019, and clinical trial results demonstrated reduction in spinal curvature with benefits that outweigh risks in select skeletally immature patients.

When making coverage determinations for dual product eligible members, the Plan refers to CMS National and Local Coverage Determinations and MassHealth medical necessity determinations; where CMS and MassHealth guidance is not available, the Plan applies its internally developed medical necessity guidelines and utilization management processes. The policy has been periodically reviewed by the Medical Policy Approval Committee (MPAC) with administrative and coding updates (including CPT additions effective January 1, 2024) and most recently renewed without changes effective January 1, 2026.

Revision History

November 2023coding update

Coding updated per AMA CPT; codes 22836 and 22837 added effective January 1, 2024

November 19, 2025administrative reviewLatest

Reviewed by MPAC for annual review, renewed without changes effective January 1, 2026; administrative updates in December 2025 effective January 1, 2026 (no clinical policy changes)