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AetnaAll Plans · Coverage · Medical Policy · Orthopedics, Pediatrics, Chiropractic +1 moreMedium impact

Idiopathic Scoliosis (CPB 0398, reviewed 2026-09-28)

Effective date
Not stated in the notice
Identified
Oct 3, 2026

Summary

Aetna considers spinal fusion with instrumentation and bone grafting medically necessary for idiopathic scoliosis with a curve of 40 degrees or greater in an adolescent younger than 18, or a curve of 50 degrees or greater in a young adult aged 18 to 25. Lumbar vertebral body tethering is considered medically necessary for skeletally immature members with lumbar idiopathic scoliosis whose lumbar curve is between 40 and 65 degrees, whose curve reduces by 50 percent or more on side-bending radiographs, and who have no sagittal imbalance, while vertebral body tethering for thoracic scoliosis is listed as experimental, investigational or unproven. Braces are considered medically necessary when the Boston, Charleston, Milwaukee, Providence, Rigo-Cheneau, standard TLSO and other listed types are prescribed by a qualified practitioner and furnished by a licensed or certified orthotist or prosthetist within six months of the prescription, while the Copes, SpineCor, Rosenberger, ScoliBrace, UNYQ and Whisper braces are considered experimental, investigational or unproven.

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What to do

Action · 11 steps
01Billing team: Before submitting a claim for a scoliosis orthosis, confirm a Standard Written Order was communicated to the supplier, because claims billed without a completed SWO will be denied as not medically necessary.
02The SWO must include the member's name or identification number, the order date, a general description of the item (HCPCS code, code narrative, or brand name and model), every concurrently ordered option, accessory or feature listed separately, each supply listed separately with its HCPCS code and quantity, and the treating practitioner's name, NPI and signature.
03Treating practitioners are physicians (MD or DO), physician assistants, nurse practitioners and clinical nurse specialists, so prosthetists, orthotists, physical therapists and occupational therapists cannot write the prescription.
04Get a new prescription from the treating practitioner each time a new device or repair is requisitioned, and confirm the orthosis is provided within six months of the prescription date.
05Keep medical record documentation that supports medical necessity and matches any supplier-prepared statement or attestation, since statements and attestations alone are not sufficient.
06Bill HCPCS L1005, L1300 and L1310 without add-on codes, because add-on codes with these codes are incorrect coding, and do not use L0999 or L1499 as base codes, to bill features already included in a base code, or where a specific L-code exists.
07Add-on codes for L1000 and L1200 are not separately payable without their base code.
08Do not bill separately for CAD-CAM or 3-D printing, fitting, follow-up appointments, digital scanning, or X-ray evaluation, because these are included in the orthosis allowance.
09For spinal fusion in members 21 or older, confirm the member is nicotine-free for at least 6 weeks before surgery, and where there is recent nicotine use include a lab report (not a surgeon summary) showing a blood and/or urine nicotine level of 10 ng/ml or less drawn within 6 weeks before surgery, unless spinal cord compression or myelopathy, cauda equina syndrome, severe weakness or progressive weakness is present.
10For lumbar vertebral body tethering, confirm the record documents that the member and family were counseled on conversion-to-fusion risk, higher revision rates and tether breakage rates compared with posterior spinal fusion.
11Some plans exclude durable medical equipment, so check the member's benefit plan before billing orthoses.

Codes mentioned

20661206642093020931209362093720938222122221422216225052283622837228382284022842228432284422845228462284722848228492285222853228542728029010770729701497032E0744L0999L1000L1005L1006L1007L1010L1020L1025L1030L1040L1050L1060L1070L1080L1085L1090L1100L1110L1120L1200L1210L1220L1230L1240L1250L1260L1270L1280L1290L1300L1310L1499M41.04M41.06M41.24M41.26M41.34M41.44M41.54M41.84M41.114M41.116M41.124M41.126Z13.828Z72.0

Original notice

Idiopathic Scoliosis (CPB 0398, reviewed 2026-09-28)
aetna.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

Aetna policiesOrthopedicsPediatricsChiropracticPhysical TherapyCode 20661Code 20664Code 20930Code 20931Code 20936Code 20937Code 20938Code 22212Code 22214Code 22216Code 22505Code 22836Code 22837Code 22838Code 22840Code 22842Code 22843Code 22844Code 22845Code 22846Code 22847Code 22848Code 22849Code 22852Code 22853Code 22854Code 27280Code 29010Code 77072Code 97014Code 97032Code E0744Code L0999Code L1000Code L1005Code L1006Code L1007Code L1010Code L1020Code L1025Code L1030Code L1040Code L1050Code L1060Code L1070Code L1080Code L1085Code L1090Code L1100Code L1110Code L1120Code L1200Code L1210Code L1220Code L1230Code L1240Code L1250Code L1260Code L1270Code L1280Code L1290Code L1300Code L1310Code L1499Code M41.04Code M41.06Code M41.24Code M41.26Code M41.34Code M41.44Code M41.54Code M41.84Code M41.114Code M41.116Code M41.124Code M41.126Code Z13.828Code Z72.0

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