Policy and Coverage Criteria:

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

1. Idiopathic scoliosis of thoracic and/or lumbar spine
2. 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
3. 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
4. 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
5. Tethering device must be FDA approved; AND
6. 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
7. 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