POLICY AND PROCEDURE MANUAL
Policy Title: Scoliosis Surgery
Policy Number: F.12
Primary Department: Medical Management
Affiliated Department(s): N/A
NCQA Standard: N/A
URAC Standard: N/A
Last Revision Date: 04/10/2015
Next Review Date: 06/2016
Revision Dates: 04/10/2015
Review Dates: 06/26/2015
Effective Date: 06/26/2015
Special Instructions Alert: N/A
State/Program
Medicare:
Medicaid:
Commercial:
MI
☐SNP
☐MA
☐MMAI
☐PDP
☐TANF ☐SPD
☐SCHIP
☐Exchange
IL
☐SNP
☐MA
☐MMAI
☐PDP
☐TANF ☐SPD
☐SCHIP
☐Exchange
IA
☐SNP
☐MMAI
☐MA ☐PDP
☐TANF ☐SPD
☐SCHIP
☐Exchange
☐SNP
☐MA
☐MMAI
☐PDP
☐TANF ☐SPD
☐SCHIP
☐Exchange
☐SNP ☐MMAI
☐MA ☐PDP
☐TANF ☐SPD
☐SCHIP
☐Exchange
Definitions:
Scoliosis A congenital lateral curvature of the spine
In spinal fusion for Scoliosis rods, hooks, wires, or screws are attached to the curved part of the backbone and
Spinal
the spine is straightened. Small pieces of bone are then put over the spine. The bone pieces will grow together
fusion
with the spinal bone, fusing it into the proper position. Spinal fusion is major surgery that usually takes
several hours to complete. Although the basic procedure is the same, a variety of specialized techniques can
be used to do spinal fusion. Many different types of spinal instrumentation are used to treat scoliosis. Also,
techniques vary, from what type of hooks or rods are used to whether the surgery is done from the front of the
body or from the back. The method chosen will depend on a number of things, including the child's age,
spinal maturity, the location and severity of the curve, the clinical opinion of the surgeon, and the preference
of the child and parents. The surgical technique most often used to straighten and stabilize the spine is to do
surgery from the back, called the posterior approach. Another option is to do the surgery from the front of the
body, called the anterior approach.
Policy: Scoliosis may be classified as functional or structural. Functional scoliosis may be transient or fairly
persistent, but is not associated with any structural alterations. Structural scoliosis involves a fixed lateral curve
with rotation, and is associated with many conditions including neuropathic diseases/disorders such as cerebral
palsy, poliomyelitis, and muscular dystrophy; congenital causes such as failure of formation or segmentation,
and myelomeningocele; traumatic causes such as fracture or dislocation (non-paralytic) and post-radiation; soft
tissue contractures such as post-empyema and burns; osteochondrodystrophies such as achondroplasia and
spondyloepiphyseal dysplasia; tumor; and rheumatoid disease. However, the most common type of structural
scoliosis is idiopathic scoliosis. Although idiopathic scoliosis is thought to have a genetic predisposition, its
exact cause is still unknown.
Medical Management
Policy: F.12
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Idiopathic scoliosis can be further divided into 3 categories: (i) infantile (0 to 3 years of age), (ii) juvenile (3 to
9 years of age), and (iii) adolescent (10 years of age to maturity). Idiopathic scoliosis most frequently affects
young girls. The spinal curvature that persists after skeletal maturity is termed adult scoliosis.
The traditional treatment for adolescent idiopathic scoliosis is the use of a supportive brace, and it is the primary
treatment for idiopathic scoliosis. Standard scoliosis braces include the Milwaukee brace and the Boston brace.
Torso exercises to increase muscle strength have been used in conjunction with braces, but there is inadequate
evidence to support this. Since bracing is restrictive and must be worn 23 hours a day for up to several years,
non-compliance has been estimated to be 20 to 50 % (Moe and Kettelson, 1970). Additionally, this method is
associated with side effects such as anxiety, depression, and sleep disturbance.
The peer-reviewed medical literature suggest that surgery is indicated for growing children whose curve has
exceeded 40 degrees; for individuals of any age whose curve is greater than 50 degrees; individuals with
scoliosis-related pain that is refractory to conservative treatments; and patients with thoracic lordosis that can't
be treated conservatively.
Procedure: Meridian Health Plan (MHP) considers surgery (e.g., spinal fusion with instrumentation and bone
grafting) for the treatment of idiopathic scoliosis medically necessary for any of the following conditions:
1. An increasing curve (greater than 40 degrees) in a growing child who is skeletally immature; or
2. Scoliosis related pain that is refractory to conservative treatments; or
3. Severe deformity (curve greater than 50 degrees) with trunk asymmetry in children and adolescents and
or associated with functional impairment in skeletally mature adolescents or adults; or
4. Thoracic lordosis that cannot be treated conservatively.
When these criteria are not met, idiopathic scoliosis surgery is considered experimental and investigational.
5. MHP considers growing rods technique medically necessary in the treatment of idiopathic scoliosis for
persons who meet criteria for surgery above. Note: Please note this does not apply to the expandable
magnetic growing rod (Phoenix Growing Rod device) which is currently considered investigational and
experimental. Scoliosis braces and casts
a. MHP considers the following types of braces and casts medically necessary DME for the
treatment of scoliosis:
1. Boston scoliosis brace
2. Charleston scoliosis brace
3. Milwaukee scoliosis brace
4. Providence brace
5. Rigo-Cheneau brace
6. Risser jacket
7. Standard thoracolumbrosacral orthosis orthosis (TLSO).
b. MHP considers the following types of scoliosis braces experimental and investigational because
their effectiveness has not been established:
1. Copes scoliosis brace
2. Rosenberger brace
3. SpineCor Dynamic Corrective Brace.
6. MHP considers spinal unloading devices (e.g., LTX 3000, Orthotrac) experimental and investigational
for treatment of scoliosis because their effectiveness has not been established.
7. MHP considers vertebral body stapling and vertebral body tethering experimental and investigational for
the treatment of scoliosis because its effectiveness has not been established.
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Policy: F.12
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8. MHP considers resistive exercises experimental and investigational for the treatment of scoliosis
because their effectiveness for this indication has not been established.
9. MHP considers spinal manipulation experimental and investigational for the treatment of adult scoliosis
because its effectiveness for this indication has not been established.
10. MHP considers whole body vibration experimental and investigational for the treatment of scoliosis
because its effectiveness has not been established.
11. MHP considers ScoliScore and other genetic testing (e.g., the CHD7 gene, the matrilin-1 gene
(MATN1) and the transforming growth factor beta 1 (TGFB1) gene; not an all-inclusive list)
experimental and investigational for predicting progression of adolescent idiopathic scoliosis because
their effectiveness has not been established.
12. MHP considers the following interventions for the treatment of scoliosis experimental and
investigational because their effectiveness has not been established:
a. The CLEAR protocol (The CLEAR protocol for treating scoliosis consists of 3 components: (i)
Mix, (ii) Fix, and (iii) Set. The objective of the first part of the protocol (Mix) is to warm up the
spine, and prepare it for the rest of the treatment. In this portion of the protocol the patient performs
several activities to warm up and loosen up the spine. These activities include the wobble chair, and
different tractioning devices designed put motion into the spine. The second part of the treatment
protocol (Fix) entails chiropractic adjustments. Chiropractors also perform other modalities that
begin to cause correction of the spinal curvatures. During the last part of the program (Set), the
patient receives several treatments that are designed to stabilize the spine in a more corrected
position. (http://www.clear-institute.org/TheCLEARScoliosisMethod/tabid/876/Default.aspx)
There is currently insufficient evidence that chiropractic or osteopathic manipulation is effective in treating scoliosis.
1.
The inversion table
2.
The magnetically controlled growing rod (Phoenix growing rod)
3.
Sacroiliac fusion.
Special Instructions: N/A
CPT/HCPCS Codes:
20930, 20937, 22214, 22216, 22548, 22819, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22852,
29010, 27014, 27032, L1000-L1499
Approved by: __________________________________
Corporate Chief Operating Officer
Reviewed and approved by Policy and Procedure Committee:
Reviewed and approved by Medical Policy Operations Committee:
Reviewed and approved by Physician Advisory Committee:
Reviewed and approved by Corporate Compliance Committee:
Date: 06/26/2015
Date: 04/10/2015
Date: 04/24/2015
Date: 06/26/2015
Date: 07/28/2015
References:
1. Michigan Department of Community Health. Medicaid Provider Manual. (Version Date: July 1, 2015).
2. White SF, Asher MA, Lai SM, Burton DC. Patients' perception of overall function, pain, and appearance after
primary posterior instrumentation and fusion for idiopathic scoliosis. Spine. 1999;24(16):1693-1699; discussion
1699-1700. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/10472104
Medical Management
Policy: F.12
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3. University of Southern California Center for Spinal Surgery. Scoliosis Overview. Retrieved from:
http://www.uscspine.com/conditions/childrens-scoliosis.cfm
4. Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30(3):353-365. Retrieved from:
http://www.ncbi.nlm.nih.gov/pubmed/10393761
5. Reamy, Brian, Slakey, Joseph B. Adolescent Idiopathic Scoliosis: Review and Current Concepts. Am Dam
Physician. 2001 Jul 1; 64(1):111-117. Retrievedf from: http://www.aafp.org/afp/2001/0701/p111.html
6. Abraham DJ, Herkowitz HN, Katz JN. Indications for thoracic and lumbar spine fusion and trends in use. Orthop
Clin North Am. 1998;29(4):803. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/9756973
7. Sarwalk JF, Kramer A. Pediatric spinal deformity. Curr Opin Pediatr. 1998;10(1):82-86. Retrieved from:
http://www.ncbi.nlm.nih.gov/pubmed/9529645
8. Bridwell KH. Spinal instrumentation in the management of adolescent scoliosis. Clin Orthop. 1997;335:64-72.
Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/9020207
9. Delorme S, Labelle H, Aubin CE, et al. Intraoperative comparison of two instrumentation techniques for the
correction of adolescent idiopathic scoliosis. Spine.1999;24(19):2011-2017, discussion 2018. Retrieved from:
http://chinaspinetools.com.msb.medtronic.com/articles/clpp/Deformity/deformity03.pdf
10. Leung JP, Lam TP, Ng BK, et al. Posterior ISOLA segmental spinal system in the treatment of scoliosis. J
Pediatr Orthop. 2002;22(3):296-301. Retrieved from: http://journals.lww.com/pedorthopaedics/Abstract/
2002/05000/Posterior_ISOLA_Segmental_Spinal_System_in_the.5.aspx
11. Smith JA, Deviren V, Berven S, et al. Does instrumented anterior scoliosis surgery lead to kyphosis,
pseudarthrosis, or inadequate correction in adults? Spine. 2002;27(5):529-534. Retrieved from:
http://journals.lww.com/spinejournal/Abstract/2002/03010/Does_Instrumented_Anterior_Scoliosis_Surgery_Lea
d.14.aspx
State Bulletins
CMS National/Local Coverage Determination (NCD/LCD)
Medicare Managed Care Manual:
Medicaid CFR:
State Administrative Codes:
Contract Requirements:
Related Policies:
Medical Management
Policy: F.12
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