Does not require prior authorization.
Pectus Carinatum, Pectus Excavatum, and Poland Syndrome will be covered subject to the indications listed below.
Indications that are covered
Pectus Excavatum: Must meet all of the following for coverage of medically necessary repair:
- A Pectus Index greater than 3.25 (calculated by using chest measurements from a CT scan of the area of the chest with the greatest depression.) A Pectus Index is determined by dividing the transverse diameter of the chest by the minimal anteroposterior diameter of the chest.
- Exercise limitation with symptoms OR chest pain related to pectus excavatum present for more than six months and unresponsive to more conservative treatment. Documentation of either of these is required.
- Diminished cardiopulmonary function during exercise, documented by lung/cardiac function tests (i.e. 20% depression of cardiopulmonary function.); and
- Cardiologist/pulmonologist concurs with need for surgical correction.
Indications that are not covered
- Since Pectus Carinatum usually does not cause physical complications due to compression of the heart and lungs, repairs of this chest wall deformity are not covered.
- Repairs considered for cosmetic reasons are not eligible for coverage.
Pectus Carinatum is a deformity of the chest that causes the rib cage to push itself outward. It is sometimes referred to as "pigeon breast."
Pectus Excavatum is a deformity of the chest that causes the rib cage to have a sunken, or caved in appearance. It is sometimes referred to as "funnel chest."
Poland Syndrome is a rare breast asymmetry that occurs in adult females and sexually mature adolescent females. It is marked by immature development of the breast nipple and areola with immature development of the chest wall structures on the same side. Other characteristics of Poland syndrome include lack of development of the chest muscles, rib deformities, webbed fingers, and lack of development of the main nerve of the arm. Severe Poland syndrome may influence pulmonary function.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.