Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment Form

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Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment Medical Guideline

Service: Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment

PUM 250-0027-1812

Medical Guideline Committee Approval Q4-2025 Effective Date 03/01/2026

Coverage for Pectus excavatum, Pectus carinatum, and Poland syndrome treatment may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

This medical guideline addresses treatment of the following chest wall deformities to correct functional impairment or threat to health:

• Pectus Excavatum, a sternal depression deformity (sometimes referred to as funnel chest).
• Pectus Carinatum, a protrusion deformity of the anterior chest wall (sometimes referred to as pigeon chest). • Poland Syndrome, a partial or complete absence of pectoral muscles, which may have associated abnormalities of other chest wall muscles, or of nipples, rib cartilage, or digits.
Definition:

Cosmetic Treatment is any health care service used solely to: (1) change or improve physical appearance or self-esteem; or (2) treatment of a condition that causes no functional impairment or threat to health.

Indications of Coverage:

A. Pectus Excavatum surgical treatment with Nuss or modified Ravitch procedure is considered medically necessary when all of the following are met:

1. Chest computed tomography (CT) demonstrates Haller index, also called pectus index (PI) or pectus severity index (PSI), greater than 3.25.

2. At least one of the following is present:

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a. Echocardiography demonstrates decreased cardiac output from cardiac compression or displacement, or
b. Cardiac conduction abnormality attributed to sternal deformity, or c. Exercise pulmonary function test demonstrates exercise intolerance with results below predicted value, or d. Pulmonary function testing demonstrates decreased total lung capacity less than or equal to 80% of predicted value, or
e. Failed previous repair of Pectus Excavatum

B. Pectus Carinatum treatment with custom orthotic compression brace is considered medically necessary when all of the following are met:

1. Documentation demonstrates a functional impairment (cardiac or respiratory insufficiency)

2. Haller index of less than or equal to 2.0

3. Incomplete skeletal growth

   C. Pectus Carinatum surgical treatment is considered medically necessary for failed previous repair of Pectus Carinatum, or in rare cases in which all of the following are met:

4. The treating provider has documented that custom orthotic compression bracing is inappropriate or contraindicated for the individual and has provided rationale or custom orthotic compression bracing has failed.

   AND

5. Cardiopulmonary compromise due to pectus carinatum is demonstrated by any of the following:

   a. Echocardiogram shows deformity of cardiac silhouette and reduced cardiac function caused by pectus carinatum. b. Pulmonary function tests demonstrate obstructive or restrictive abnormalities caused by pectus carinatum. c. Narrow cardiac shadow and increased anterior-posterior diameter of chest wall and emphysematous-appearing lungs are demonstrated on chest x-ray or CT.

   D. Poland Syndrome surgical treatment is considered medically necessary to correct a functional deficit when all of the following are met:

6. Rib formation is absent.

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  AND

2. Documentation demonstrates functional impairment by any one of the following:

   a. Abnormal pulmonary function during exercise

   b. Decreased cardiac output or arrhythmias.

   Limitations of Coverage:

   Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

   A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

   B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

   C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

   D. The following will be considered experimental, investigational, and unproven to affect health outcomes:

3. The magnetic mini-mover procedure
4. The vacuum bell

5. Dynamic Compression System / Dynamic Compressor System (e.g., FMF® Dynamic Compressor System [DCS])

   E. Repair of a chest wall deformity solely to improve appearance or self-esteem, or for psychological or psychosocial symptoms/complaints is considered cosmetic and is not medically necessary.

   F. The following are considered cosmetic and not medically necessary when performed in association with repair of a chest wall deformity for pectus excavatum, pectus carinatum, or Poland Syndrome:

6. Mastopexy (breast lift)
7. Breast reconstruction with tissue expander(s), latissimus dorsi flap(s), or other technique(s)

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3. Breast reconstruction for symmetrical appearance
4. Insertion of breast implant/prosthesis
5. Mammoplasty
6. Areolar/nipple reconstruction
7. Revision of reconstructed breast

8. Prosthetic Inserts

   (Note: Limitation F. does not apply to breast reconstruction procedures related to mastectomy due to breast cancer)

   Documentation Required:

   • Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
   • Medical record information (including continued need/use if applicable) and medical necessity. Office visit notes, diagnostic/imaging/testing reports
   • Correct coding for the item/service that meets all the coding guidelines.

   Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

   Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

   Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

   State mandates, laws or benchmark supersede this medical guideline.

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Guideline Review History:

Implemented 01/01/20, 12/01/20, 08/01/21, 08/01/22, 08/01/23, 08/01/24, 03/01/26 Medical Guideline Committee Approval 08/30/19, 08/20/20, 07/29/21, 07/28/22, 07/27/23, 07/25/24, Q4 2025 Reviewed

08/20/20, 07/29/21, 07/28/22, 07/27/23, 07/25/24, Q4 2025 Developed 08/30/19

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; OPEN 21742 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITHOUT THORACOSCOPY 21743 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITH THORACOSCOPY