Anthem Blue Cross Connecticut CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib Form

This document addresses the use of a vertical expandable prosthetic titanium rib (VEPTR^™ DePuy SYNTHES^® Spine Inc., West Chester, PA) device as a treatment of severe progressive spinal deformities associated with thoracic insufficiency syndrome (TIS), which includes severe forms of scoliosis. TIS is defined as the inability of the thorax to support normal respiration or lung growth. The VEPTR device consists of a curved rod that conforms to the shape of the thoracic cage. This device, with clearance from the U.S. Food and Drug Administration (FDA), is surgically implanted and vertically affixed to two ribs above and below expansion thoracostomies, which are placed at the site of the vertebral deformity.

Clinical Indications

Medically Necessary:

A vertical expandable prosthetic titanium rib device, is considered medically necessary when all of the following criteria have been met (A, B, and C):

1. Use includes 
   1. Implantation; or
   2. Expansion (lengthening); or
   3. Exchange (replacement); or
   4. Conversion (rib to spine);
      and
2. The individual has any of the following conditions:
   1. Congenital scoliosis; or
   2. Neuromuscular scoliosis; or
   3. Idiopathic scoliosis (that is, infantile, juvenile, or adolescent) or
   4. Syndromic scoliosis;
      and
3. The individual meets all of the following:
   1.  Skeletally immature; and
   2. Presence of the following;
      1. Severe, progressive spinal deformity; or
      2. Three-dimensional deformity of the thorax;
         and
   3. The deformity is associated with, or places the individual at risk for, thoracic insufficiency syndrome.

Not Medically Necessary:

Use of the vertical expandable prosthetic titanium rib device is considered not medically necessary when the above criteria are not met and for all other indications.