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MP 7.01.200 Surgical Correction of Pectus Excavatum

Medical Policy
Section
Surgery
 
Original Policy Date
08:2007
Last Review Status/Date
Created local policy with literature search/August 2007
Issue
6:2007
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Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description
Pectus Excavatum (funnel chest) is a common deformity of the sternum and occurs when the sternum is posteriorly displaced, creating a funnel-shaped appearance.  There is no known etiology for the deformity, and there is significant variation in the degree of depression.  In more severe cases compromise of cardiopulmonary function can occur because of mechanical compression of the thoracic contents.  Surgical procedures, both minimally invasive (Nuss repair) and open (Ravitch repair) are capable of restoration of function in addition to cosmetic improvement.


Policy
Surgical repair of pectus excavatum is considered medically necessary when there is well-documented evidence of progression of the deformity and associated symptoms of complications that have resulted.


Policy Guidelines
Evidence of progression of the deformity may include:

  • Restrictive lower airway disease
  • Cardiac evaluation demonstrating compression-caused mitral valve prolapse, abnormal rhythm, conduction defects, or significant cardiac deformity
  • Haller CT scan index (chest transverse diameter divided by the anterior-posterior diameter) greater than 3.25
  • Exercise limitation
  • Atypical chest pain


Codes
CPT 21740-21742 21743 Reconstructive repair with thoracostomy
ICD-9 Procedure 34.74 Repair of pectus deformity
ICD- 9 Diagnosis 754.81. 738.3, 268 Pectus excavatum, congenital, acquired, rachitic
HCPCS No code  
Type of Service Surgery  
Place of Service Inpatient  

Index

Pectus Excavatum Repair


Policy History

Date Action Reason
08/07 Add policy to Surgery section New local policy
09/03/08 Update only  renumbered policy from 7.01.114 to 7.01.200


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