L1320, Thoracic, pectus carinatum orthosis, sternal compression, rigid circumferential
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Surgical repair of pectus excavatum may be considered medically necessary in children or adults when at least two of the following medical necessity criteria are met:
- A. Documented progression of the deformity with associated symptoms.
- B. Pulmonary function studies indicate components of restrictive airway disease.
- C. Haller index greater than 3.25 at end-inspiration. This Haller index is the ratio derived from a chest CT or magnetic resonance imaging (MRI) scan by dividing the transverse diameter by the anterior-posterior diameter.
- D. Cardiac evaluation (electrocardiogram [EKG], chest CT, and/or echocardiogram) demonstrates compression-caused mitral valve prolapse, abnormal rhythm, conduction abnormalities, or significant cardiac deformity.
1 Active Policy
REGENCE-SUR12.02, Pectus Excavatum and Carinatum Treatment
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