21742
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Well-documented evidence in the medical record of complications arising from the sternal deformity (e.g., clinical notes documenting symptoms/signs and relationship to deformity).
- Echocardiography demonstrating cardiac compression/displacement with decreased cardiac output when cardiac compromise is claimed.
- Pulmonary function testing demonstrating total lung capacity (TLC) ≤ 80% of predicted value when lung compression is claimed.
- Exercise pulmonary function tests demonstrating objective evidence of exercise intolerance (values below predicted) when exercise intolerance is claimed.
Key Coverage Criteria
- Surgical repair of severe pectus excavatum deformities that cause functional deficit when done for medical reasons in members who meet all of the following criteria:
- An electrocardiogram or echocardiogram has been done if a heart murmur or known heart disease is present to define the relationship of the cardiac problem to the sternal deformity;
- Well-documented evidence of complications arising from the sternal deformity. Complications include but may not be limited to: cardiac compression, displacement results in decreased cardiac output demonstrated by echocardiography; or Reduced lung capacity as demonstrated by a total lung capacity (TLC) less than or equal to 80% of predictive value per pulmonary function testing; or There is objective evidence of exercise intolerance due to reduced lung capacity as documented by exercise pulmonary [...]
- A CT scan of the chest demonstrates a pectus index, derived from dividing the transverse diameter of the chest by the anterior-posterior diameter, greater than 3.25;
- Surgical reconstruction of musculoskeletal chest wall deformities (congenital absence or hypoplasia of pectoralis major and minor muscles; congenital partial absence of the upper costal cartilage) associated with Poland's syndrome that cause functional impairment (also see CPB 0185 - Breast Reconstructive Surgery).
- CPT codes covered if selection criteria are met for pectus excavatum: 21740, 21742, 21743.
3 Active Policies
AETNA-CPB-0272 — Pectus Excavatum and Poland's Syndrome: Surgical Correction
ANTHEM-MP-A050277 — ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
REGENCE-SUR12.02 — Pectus Excavatum and Carinatum Treatment
Related Codes
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