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Coverage criteria policies

Pectus excavatum and pectus carinatum

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for repair of pectus excavatum and pectus carinatum

Coverage

Repair of pectus excavatum or carinatum may be covered subject to the indications listed below and per your plan documents.

Indications that are covered

All of the following criteria must be met for coverage of repair of pectus excavatum:

  1. A Haller Index greater than 3.25 (calculated by using chest measurements from a CT scan of the area of the chest with the greatest depression.)
  2. 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.
  3. Diminished cardiopulmonary function during exercise, documented by lung/cardiac function tests (i.e. 20% depression of cardiopulmonary function.); and
  4. Cardiologist/pulmonologist concurs with need for surgical correction.

Indications that are not covered

  1. Pectus carinatum repair is not covered unless there is documentation in the medical record of related functional problems.
  2. Repairs for cosmetic reasons are not covered.

Definition

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."

Haller index is the ratio between the horizontal distance of the inside of the ribcage and the shortest distance between the vertebrae and sternum.

Products

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.

References

  1. Hayes, Inc. . Hayes Technology Brief. Nuss Procedure for Pectus Excavatum in Children.Lansdale, PA: Hayes, Inc; December 2010. Archived January 2014
  2. Hayes, Inc. Hayes Health Technology Brief. Orthotic Compression Bracing for Treatment of Pectus Carinatum, Lansdale, PA: Hayes, Inc.; November 2012, Archived December 2015.
  3. Mayer, O. Pectus Excavatum: Treatment. In: UpToDate, Redding, G, (Ed), UpToDate, Waltham, MA. ( (Accessed on 6/18/2018).
  4. Nuchtern, J , Mayer, O.. Pectus carinatum. In: UpToDate, Redding, G.(Ed), UpToDate, Waltham, MA. (Accessed on July 16, 2018.)

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Policy activity

  • 06/18/2001 - Date of origin
  • 06/18/2001 - Effective date
Review date
  • 07/2018

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