ModifiedUnitedHealthcarePolicy CS170NE.J

Vertebral Body Tethering for Scoliosis (Nebraska only)

Policy governing coverage of vertebral body tethering (VBT) for treatment of scoliosis in Nebraska; applies to Nebraska providers and members. Defines coverage stance, applicable procedure codes, and summarizes the evidence base.

Policy Summary

PayerUnitedHealthcare

PolicyVertebral Body Tethering for Scoliosis (Nebraska only)

Policy CodePolicy CS170NE.J

Change TypeAdded CPT codescontent refreshstate-specific version

Effective DateMarch 1, 2025

Next Review Date

Key ActionObtain prior authorization with documentation of skeletal maturity, Cobb angle, and prior bracing failure or intolerance when submitting VBT procedure codes.

SourceLink

POLICY UPDATE CHANGES

Applicable Codes: Added CPT codes 0790T and 22838.

Supporting Information sections (Description of Services, Clinical Evidence, FDA, and References) were updated to reflect the most current information.

Created state-specific policy version for the state of Nebraska (no change to coverage guidelines).

Not medically necessaryCoverage stance

8 codesProcedure codes

~20–50%Tether breakage

8–10%Reoperation rate

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LimitedEvidence quality

30–65°FDA Cobb range

Coverage Determination and Criteria

Not medically necessary — general

Coverage determination:

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

Applies to Nebraska per policy application.

Study-derived candidate characteristics and outcome considerations

Evidence-based considerations and commonly reported study inclusion characteristics (not formal coverage approval criteria — these reflect what published studies used):

Common study inclusion elements: Patients typically were adolescents with idiopathic thoracic scoliosis, age approximately 9–16 years; skeletal immaturity often defined as Sanders ≤4 and/or Risser ≤2–3; primary thoracic curve magnitude commonly in the ~40–70° range; no prior spine surgery.as reported in cited studies

Descriptive of study populations (Mathew 2022; Shin 2021).

Reported outcome considerations: Outcomes frequently reported include percent curve correction (many studies show less correction with VBT versus PSF), rates of tether/cable breakage, reoperation/revision rates, preservation of spinal motion, and patient-reported outcomes; long-term durability through skeletal maturity is uncertain.n/a

Meta-analyses report higher complication and reoperation rates for anterior VBT compared with PSF (Shin 2021); individual cohorts report tether breakage rates ~19% at 2 years (Mathew 2022).

Coverage Criteria for VBT

Covered when ALL of the following are met (as supported by device HDE indications and society guidance):

Population and indications: Patient is skeletally immature (e.g., Risser ≤ 2 or Sanders ≤ 5) AND has progressive idiopathic scoliosis with a major Cobb angle 30–65°.Risser ≤ 2 or Sanders ≤ 5; Cobb 30–65°

Reflects FDA HDE indications (The Tether, REFLECT) and POSNA/SRS position statements.

Prior conservative management: Documented failure of bracing or intolerance to bracing prior to surgical consideration.Prior bracing attempted and failed or intolerant

Consistent with FDA HDE device labeling and society guidance.

Operative setting and surgeon qualifications: Procedure performed in an appropriate specialist center by surgeons trained in anterior spinal surgery or under active institutional review (IRB) when applicable.

Situations Not Supported

Not covered / not supported when ANY of the following apply:

Skeletally mature patients: Use of anterior non-fusion instrumentation or vertebral body tethering in skeletally mature individuals.Skeletally mature

POSNA and SRS do not support use or reimbursement in skeletally mature patients.

Insufficient evidence contexts: Use of VBT outside of research settings where local requirements or national guidance (for example, NICE) limit use to research only or require specialist-center performance.Not performed in research or specialist center when required

NICE recommends VBT only within research and specialist centers due to limited evidence and concerns about serious complications.

Use outside FDA HDE indications: Procedures performed outside the device-specific indications (for example, patients without failed/intolerant bracing or Cobb angles outside 30–65°) or where osseous anatomy is inadequate for screw fixation.

This medical policy applies only to the State of Nebraska. Vertebral body tethering (VBT) for the treatment of scoliosis is considered unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

Multiple evidence reviews and published studies identify important limitations in the VBT literature — most studies are retrospective, observational, or small case series, with inconsistent comparative data and limited follow‑up into skeletal maturity. Reviews (Hayes, Roser et al.) conclude that the quality of evidence is low or inconclusive and that additional high‑quality research (including randomized trials and longer‑term registry follow‑up) is needed to establish safety and sustained benefit.

POSNA and SRS support VBT under stated device and patient indications for skeletally immature patients (characterized by Risser ≤ 2 or Sanders ≤ 5) with idiopathic scoliosis and major Cobb angles in the 30–65° range, but explicitly do not support use or reimbursement of anterior non‑fusion instrumentation in skeletally mature individuals where no evidence supports benefit.

Given the limited quantity and low quality of evidence, the relatively high reported rates of complications (including tether breakage) and revision surgery, and lack of long‑term durability data to skeletal maturity, VBT is classified in this policy as unproven / not medically necessary.

Independent evidence assessments (Hayes) and systematic reviews/meta‑analyses (Roser et al.) have found that available studies are mostly retrospective and of low quality, that complication and reoperation rates are notable, and that comparative effectiveness versus posterior spinal fusion is not established — leading these reviewers to call for more rigorous studies before routine adoption.

Because of limited evidence and concerns about serious complications, national guidance (NICE) recommends that VBT be used only in the context of research and in specialist centers; professional societies (POSNA/SRS) similarly recommend restricting use to patients who meet device indications and to settings with appropriate oversight and surgeon expertise.

Procedure and Product Codes

Referenced procedure/HCPCS/CPT 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 Codes (added)CPT

0790T	Added CPT code (as listed in policy history)
22838	Added CPT code (as listed in policy history)

FDA product codemixed

QHP	FDA product code referenced for HDE devices (informational)

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required for VBT Procedure Codes

Prior authorization is required for vertebral body tethering (VBT) procedure codes before scheduling. Submit a preauthorization request that includes the clinical documentation described below. Lack of prior authorization may result in claim denial or delayed payment.

Affected CPT/Codes: 0656T, 0657T, 0790T, 22836, 22837, 22838, 22899
Submit documentation at time of request to expedite review

Denial Risk

Denial Risk for VBT

VBT is considered investigational/unproven by this policy. Requests for VBT have a higher risk of denial when submitted without persuasive clinical justification or when clinical criteria and device indications are not met.

Denial risk is elevated if documentation does not show failure/intolerance of bracing or if patient is skeletally mature

Clinical Background and Definitions

Adolescent idiopathic scoliosis (AIS) is a lateral and rotational curvature of the spine occurring in children and adolescents (commonly defined as ages 10–18) and is diagnosed when the Cobb angle is ≥10°. Progressive or larger curves may cause functional limitations, pulmonary compromise, and reduced quality of life; treatment choices (observation, bracing, or surgery) are guided by curve magnitude, skeletal maturity, and progression risk. Vertebral body tethering is a fusionless, anterior growth‑modulation technique intended primarily for skeletally immature patients with progressive thoracic curves to correct deformity while preserving motion.

Adolescent idiopathic scoliosis (AIS)

DefinitionLateral curvature of the spine of unknown cause with Cobb angle ≥10°, occurring in children/adolescents aged 10–18 years.

Typical clinical impactProgressive condition that usually worsens before skeletal maturity; curves >40° at maturity often progress into adulthood and can cause pulmonary and quality-of-life issues.

Age rangeOccurs in individuals aged 10–18 years.

Policy relevanceDiagnosis required when documenting indications for vertebral body tethering (VBT) or alternative treatments.

Policy Updates

2025-11-01state-specific version createdLatest

Created state-specific policy version for Nebraska; no change to coverage guidelines.

2025-03-01codes_added_and_supporting_info_updated

Applicable CPT codes 0790T and 22838 were added to the policy and supporting sections (Description of Services, Clinical Evidence, FDA, References) were updated.

Policy Summary

PayerUnitedHealthcare

PolicyVertebral Body Tethering for Scoliosis (Nebraska only)

Policy CodePolicy CS170NE.J

Change TypeAdded CPT codescontent refreshstate-specific version

Effective DateMarch 1, 2025

Next Review Date

Key ActionObtain prior authorization with documentation of skeletal maturity, Cobb angle, and prior bracing failure or intolerance when submitting VBT procedure codes.

SourceLink

On This Page

Specialist center / surgeon training

NICE recommends performance only in specialist centers; POSNA/SRS reference surgeon/center experience and IRB oversight for some programs.

Outside HDE labeling (e.g., Cobb outside 30–65°, no prior bracing failure/intolerance)

FDA HDE labeling for The Tether and REFLECT specifies skeletally immature patients with prior failed/intolerant bracing and Cobb 30–65°.

Denial likely when requested outside FDA HDE device indications (see FDA section)

Note

Evidence Limitations May Trigger Prior Authorization Scrutiny

Because the evidence base for VBT is limited and of low quality, preauthorization reviewers may apply heightened scrutiny. Expect requests to be reviewed for study quality, long‑term outcomes, complication and reoperation rates, and comparative effectiveness versus posterior spinal fusion (PSF).

Reviewers will assess published complication and reoperation rates and the quality of supporting studies
Requests citing limited or low‑quality evidence may be denied or referred for peer review

Denial Risk

Risk When Outside Device Indications

Coverage decisions may be affected when VBT is requested for indications outside device labeling. For FDA‑cleared HDE devices (The Tether™, REFLECT™), coverage consideration is limited to skeletally immature patients within labeled Cobb angle ranges and who have failed/intolerant to bracing. Use outside those device indications increases denial risk.

Device indication limits: skeletally immature, major Cobb angle 30–65°, failed/intolerant to bracing
Requests for skeletally mature patients or Cobb angles outside labeled range are at high risk for denial

Documentation Required