Surgical Repair of Pectus Excavatum*

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: 

  • Malek MH, Fonkalsrud EW, Cooper CB. Ventilatory and cardiovascular responses to exercise in patients with pectus excavatum. Chest. 2003 Sep; 124(3):870-82.
  • Wynn SR, Driscoll DJ, Ostrom NK, et al. Exercise cardiorespiratory function in adolescents with pectus excavatum. Observations before and after operation. J Thorac Cardiovasc Surg. 1990 Jan; 99(1):41-7.
  • Cahill JL, Lees GM, Robertson HT. A summary of preoperative and postoperative cardiorespiratory performance in patients undergoing pectus excavatum and carinatum repair. J Pediatr Surg. 1984 Aug; 19(4):430-3.
  • Rowland T, Moriarty K, Banever G. Effect of pectus excavatum deformity on cardiorespiratory fitness in adolescent boys. Archives Pediatr Adolesc Med. 2005 Nov; 159(11):1069-73.
  • Kowalewski J, Barcikowski S, Brocki M. Cardiorespiratory function before and after operation for pectus excavatum: medium-term results. Eur J Cardiothorac Surg. 1998 Mar; 13(3):275-9.
  • Bawazir OA, Montgomery M, Harder J, Sigalet DL. Midterm evaluation of cardiopulmonary effects of closed repair for pectus excavatum. J Pediatr Surg. 2005 May; 40(5):863-7.

  • Coln E, Carrasco J, Coln D. Demonstrating relief of cardiac compression with the Nuss minimally invasive repair for pectus excavatum. J Pediatr Surg. 2006 Apr; 41(4):683-6.

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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.

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