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Medical Policy: 07.01.33
Original Effective Date: October 2006
Reviewed: December 2007
Revised:
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
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.
Prior approval is recommended. Submit a prior approval now.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- CPT code 21740 Reconstructive repair of pectus excavatum or carinatum; open
- CPT code 21742 Minimally invasive approach (Nuss procedure), without thoracoscopy
- CPT code 21743 Minimally invasive approach (Nuss procedure), with thoracoscopy
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Selected References:
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, IA 50309
*Prior Approval is recommended for this policy.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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