Point32 Anterior Vertebral Body Tethering Form
This procedure is not covered
Policy and Coverage Criteria:
The Plan considers anterior vertebral body tethering as medically necessary when documentation confirms ALL of the following:
- Idiopathic scoliosis of thoracic and/or lumbar spine
- Radiographic imaging confirms the following:
- Major Cobb angle of 35 to 65 degrees and osseous structure is dimensionally adequate to
accommodate screw fixation; and - Cobb angle decreases in magnitude below 30 degrees on bending films
- Major Cobb angle of 35 to 65 degrees and osseous structure is dimensionally adequate to
- Progressive curvature that has not responded to one of the following conservative treatment options:
- Failed external bracing defined as curvature progression greater than 5 degrees despite external
brace wear; or - External bracing is not/no longer indicated secondary to skeletal maturity or severe scoliosis
(greater than 45 degrees) - Documentation of intolerance to external brace wear as prescribed despite reasonable efforts to improve brace fit, comfort, and brace wear compliance
- Failed external bracing defined as curvature progression greater than 5 degrees despite external
- Radiographic imaging confirms skeletal immaturity, defined as at least one of the following:
- Risser grade 0-2 and under; or
- Sanders Skeletal Maturation Stage (SMS) less than 5
- Tethering device must be FDA approved; AND
- Qualified orthopedic/spine specialist trained and with experience in VBT technique has completed in
person evaluation and has documented member's suitability for VBT and the rationale for VBT procedure - Vertebral body tethering procedure will be performed by qualified orthopedic/spine specialist trained and with experience in VBT technique at a facility with appropriate experience and expertise in VBT procedure
Exclusions:
The Plan considers vertebral body tethering as experimental and investigational for all other indications. In addition, The Plan does not cover:
- 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 a 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