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Medical Policy: 07.01.33
Original Effective Date: October 2006
Reviewed: September 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Pectus excavatum is one of the most common major congenital anomalies, occurring in approximately 1 in every 400 births. While typically recognized in infancy, it becomes much more severe during adolescent growth with easy fatigue, exertional dyspnea, decreased physical endurance, anterior chest wall pain, and tachycardia. The heart may be deviated into the left chest to varying degrees leading to reduction in stroke volume and cardiac output. Pulmonary expansion is confined, resulting in a restrictive defect. Repair is recommended for patients who are symptomatic and who demonstrate a markedly elevated pectus severity index.
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Prior Approval:
Not applicable
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Policy:
Surgical repair of pectus excavatum may be considered medically necessary in patients with:
- A chest wall index (Haller score) greater than 3.5 as determined by CT scan
AND any of the following:
- Cardiopulmonary impairment documented by respiratory or cardiac function tests
- Documented exercise limitation
- Atypical chest pain AND an EKG or echocardiogram if a heart murmur or known heart disease is present to define the relationship of the cardiac problem to the sternal deformity
Surgical repair of pectus excavatum in patients not meeting the above criteria is considered not medically necessary.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 21740 Reconstructive repair of pectus excavatum or carinatum; open
- 21742 Minimally invasive approach (Nuss procedure), without thoracoscopy
- 21743 Minimally invasive approach (Nuss procedure), with thoracoscopy
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Selected References:
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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