Vertebral Body Tethering for Scoliosis (for North Carolina Only)

Coverage Summary & Rationale

This UnitedHealthcare coverage policy applies only to North Carolina and addresses vertebral body tethering (VBT) for the treatment of scoliosis. Effective March 1, 2025, the policy states that VBT is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy and is considered not covered for cosmetic purposes under the policy stance.

VBT is evaluated here as a fusionless, growth-modulating surgical alternative to spinal fusion for skeletally immature patients with progressive adolescent idiopathic scoliosis (AIS). The policy scope includes coverage rationale, applicable procedure codes, device/FDA information, clinical evidence, and provider expectations specific to North Carolina.

Surface thresholds

Cobb angle threshold30–65° (major Cobb angle)

Skeletal maturity requirementSkeletally immature (examples: Risser ≤ 2; Sanders staging ranges referenced by societies)

Intended populationProgressive adolescent idiopathic scoliosis patients who have failed or are intolerant to bracing

Policy stanceVertebral body tethering is considered unproven and not medically necessary (not covered) due to insufficient evidence of safety/efficacy

Quick implementation noteOsseous structure must be adequate for screw fixation as determined by radiographic imaging (per device HDE)

Coverage Rationale

Policy statement on medical necessity:

Vertebral body tethering for the treatment of scoliosis is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization implication

Policy defines VBT as unproven and not medically necessary; providers should expect denial risk and that benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

0656T
0657T
0790T
22836
22837
22838
22899

Prior Authorization

Coverage may follow device indication and payor rules

Applicable Codes

Referenced Procedure CodesCPT

0656T	Anterior lumbar or thoracolumbar vertebral body tethering; up to 7 vertebral segments.
0657T	Anterior lumbar or thoracolumbar vertebral body tethering; 8 or more vertebral segments.
0790T	Revision (e.g., augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed.
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; 8 or more vertebral segments.
22838	Revision (e.g., augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed.
22899	Unlisted procedure, spine

Applicable CPT (added)CPT

0790T	New/added CPT code referenced in revision history
22838	New/added CPT code referenced in revision history

FDA product code referencedmixed

QHP	FDA product code used for The Tether and REFLECT HDE listings

The listing of procedure codes in this policy (e.g., 0656T, 0657T, 0790T, 22836, 22837, 22838, 22899) is provided for reference only and does not imply that the service is covered or that reimbursement is guaranteed. Providers should document clinical justification per payer/contractual requirements and be prepared for denials consistent with the policy defining VBT as unproven; prior authorization or credentialing requirements may apply and documentation of failed bracing, skeletal immaturity, and informed consent is expected.

Clinical Evidence & Definitions

Vertebral body tethering (VBT) is a fusionless, anterior growth-modulation surgical technique that secures vertebral body screws to a tensioned flexible cord on the convex side of the spine to modulate growth and correct progressive adolescent idiopathic scoliosis. VBT may use single or dual cords and can be performed via anterior thoracotomy, thoracoscopic, or mini-open approaches; surgical revision to replace, remove, or augment hardware may be required for complications such as inadequate correction, overcorrection, or cord breakage. VBT is intended for skeletally immature patients with a major Cobb angle of 30 to 65° who have failed or are intolerant of bracing.

Study / Source	Key findings
Systematic review (Alasadi et al. 2024)	26 studies, 1,366 patients; tether breakage ~20.8% (0–36%), revision surgery 8.3%, conversion to PSF 2.4%; pulmonary complications reported in 7.0% (range 3.3–80%).
Cahill et al. (2024) - registry	208 pts; radiographic tether breakage 36%; estimated cumulative breakage 19% at 24 months and 50% at 36 months; 28% of those with breakage had reoperation; 12% converted to PSF (breakage associated with higher conversion rate: 12% vs 2%).
Mariscal et al. (2023) - meta-analysis	12 studies, 538 pts; demonstrated coronal correction; most common complications overcorrection (8.0%) and tether breakage (5.9%); reoperation rate 10.1%.
Roser et al. (2023) - systematic review/meta-analysis	19 studies, 677 pts; mean Cobb reduced from 47.8° to 22.2°; overall complication rate 23%; tether breakage 21.9%; spinal fusion rate 7.2%.
Zhu et al. (2022) - single-arm meta-analysis	26 studies, 1,045 pts; overall clinical success ~73%; pooled unplanned reoperation ~8.7%; overall complication incidence ~36.8%; subgroup with >36 months follow-up showed increased reoperation and complications but low conversion to PSF (~7.2%).
Shin et al. (2021) - meta-analysis comparing VBT vs PSF	Pooled complication rates: VBT 26% vs PSF 2%; reoperation: VBT 14.1% vs PSF 0.6%; with ≥36 months follow-up VBT reoperation 24.7% vs PSF 1.8%; deformity correction and mid-term SRS-22 similar.
Mathew et al. (2022) - matched study VBT vs PSF	VBT had lower operative time, blood loss, LOS; success (no fusion & Cobb <35° at 2 years) 77% for VBT vs 96% for PSF; cord breakage at 2 years 19%.
Siu et al. (2023) - retrospective cohort comparison	VBT had lower length of stay, lower opioid use, and less blood loss vs PSF, but PSF achieved greater curve reduction (79% vs 63%); revision after VBT 39% vs PSF 17% (p=0.09).
Meyers et al. (2021) - early morbidity (184 cases)	Early operative morbidity: major complications 3.3%, minor 3.3%; overall 30-day complication rate 6.5%; rib resection associated with higher major complication rate (13.6% vs 1.9%).
Pehlivanoglu et al. (2021) - comparative functional outcomes	VBT preserved lumbar ROM and showed superior SRS-22 and SF-36 scores versus PSF but study limited by retrospective design and small size; safety outcomes less well characterized.

Glossary: AIS = Adolescent idiopathic scoliosis — lateral curvature of the spine of unknown cause with Cobb angle ≥ 10° in children/adolescents aged 10–18 years; Cobb angle = radiographic measure of spinal curvature used to quantify scoliosis severity; Risser stage = indicator of skeletal maturity based on iliac apophysis ossification; VBT = Vertebral Body Tethering, an anterior, fusionless growth-modulating surgical technique; PSF = Posterior Spinal Fusion; HDE = Humanitarian Device Exemption (FDA regulatory designation).

Revision History

11/01/2025addedLatest

Created state-specific policy version for the state of North Carolina.

03/01/2025added

Added CPT codes 0790T and 22838 to Applicable Codes.

03/01/2025revised

Updated Clinical Evidence, FDA, and References sections to reflect most current information.