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Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc.

Definitions Vertical expandable prosthetic titanium rib (VEPTR) Curved rod placed horizontally in the chest to shape the thoracic cavity for the treatment of spinal and thoracic deformities. In 2014, the FDA Center for Devices and Radiological Health (CDRH) cleared the VEPTR®-VEPTR II™ device for use in skeletally immature patients with severe, progressive spinal deformities and/or three-dimensional deformity of the thorax associated with, or at risk of, Thoracic Insufficiency Syndrome (TIS). Cobb angle Measurement of the degree of spinal curvature; the Cobb angle is considered the standard measurement to quantify a scoliosis for the purpose of measuring curve progression over time. A curve is considered to be scoliosis at a Cobb angle of ≥ 10º. Any increase ≥ 5º is regarded as a significant change; indicative of curvature progression with scoliosis considered mild at 10º–24º, moderate at 25º–50º and severe at > 50º in skeletally mature individuals.
Cobb angles > 45º are considered severe in skeletally immature persons. Ellis-van Creveld syndrome Autosomal recessive genetic disorder characterized by skeletal dysplasia. Hypoplastic thorax syndrome Examples of the syndrome include achondroplasia, Ellis van Creveld syndrome, Jarcho-Levin syndrome and Jeune's syndrome.

Jarcho-Levin syndrome Heritable axial skeleton growth disorder associated with malformation of the vertebral column and ribs. Jeune syndrome Congenital dwarfism associated with asphyxiating thoracic dystrophy. Scoliosis Musculoskeletal condition characterized by an abnormal lateral curvature of the spine. There are several different types of scoliosis that affect children and adolescents. The most common type is considered idiopathic but additional types of scoliosis include congenital, neuromuscular and syndromic scoliosis. Thoracic Insufficiency Syndrome (TIS) Rare condition defined as, "The inability of the thorax to support normal respiration or lung growth. This would include patients with progressive congenital, neuromuscular, idiopathic, or syndromic scoliosis" (FDA, 2014). TIS may include flail chest syndrome, hypoplastic thorax syndrome, as well as rib fusion and scoliosis.

Related Medical Guideline Surgical Correction of Chest Wall Deformities Guideline The VEPTR is considered medically necessary in the treatment of progressive thoracic insufficiency syndrome due to rib and/or chest wall defects in infants and children between 6 months of age and skeletal maturity. Rib/chest wall defects may be secondary to any of the following scoliosis conditions:

Congenital scoliosis
Neuromuscular scoliosis
Infantile and juvenile idiopathic scoliosis
Syndromic scoliosis
Non-specific chest wall defects in children that would be amenable to VEPTR treatment Limitations and Exclusions
Use of VEPTR for any condition other than those listed above (including Poland Syndrome) is not considered medically necessary due to insufficient evidence of therapeutic value.
Use of VEPTR as a scoliosis treatment in the absence of TIS (or risk for TIS) is not considered medically necessary. Procedure Codes
20999 Unlisted procedure, musculoskeletal system, general 21899 Unlisted procedure, neck or thorax
Diagnosis Codes M41.00
Infantile idiopathic scoliosis, site unspecified

M41.02
Infantile idiopathic scoliosis, cervical region
M41.03
Infantile idiopathic scoliosis, cervicothoracic region
M41.04
Infantile idiopathic scoliosis, thoracic region
M41.05
Infantile idiopathic scoliosis, thoracolumbar region
M41.06
Infantile idiopathic scoliosis, lumbar region
M41.07
Infantile idiopathic scoliosis, lumbosacral region
M41.08
Infantile idiopathic scoliosis, sacral and sacrococcygeal region
M41.11
Juvenile idiopathic scoliosis, cervical region
M41.112
Juvenile idiopathic scoliosis, cervicothoracic region
M41.113
Juvenile idiopathic scoliosis, cervicothoracic region
M41.114
Juvenile idiopathic scoliosis, thoracic region
M41.115
Juvenile idiopathic scoliosis, thoracolumbar region
M41.116
Juvenile idiopathic scoliosis, lumbar region
M41.117
Juvenile idiopathic scoliosis, lumbosacral region
M41.119
Juvenile idiopathic scoliosis, site unspecified
M41.40
Neuromuscular scoliosis, site unspecified
M41.41
Neuromuscular scoliosis, occipito-atlanto-axial region
M41.42
Neuromuscular scoliosis, cervical region
M41.43
Neuromuscular scoliosis, cervicothoracic region
M41.44
Neuromuscular scoliosis, thoracic region
M41.45
Neuromuscular scoliosis, thoracolumbar region
M41.46
Neuromuscular scoliosis, lumbar region
M41.47
Neuromuscular scoliosis, lumbosacral region
Q67.5
Congenital scoliosis NOS
Q67.8 Other congenital deformities of chest Q76.3
Congenital scoliosis due to congenital bony malformation
References American Academy of Orthopaedic Surgeons. Idiopathic Scoliosis in Children and Adolescents. Your Orthopaedic Connection. March 2015. http://orthoinfo.aaos.org/topic.cfm?topic=A00353. Accessed March 13, 2026. Campbell RM Jr, Smith MD, Mayes TC, et al. The characteristics of thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis. J Bone Joint Surg Am. 2003; 85-A(3):399-408. Campbell RM Jr, Smith MD, Mayes TC, et al. The effect of opening wedge thoracostomy on thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis. J Bone Joint Surg Am. 2004; 86-A(8):1659-1674. Campbell RM Jr. VEPTR: past experience and the future of VEPTR principles. Eur Spine J. 2013; 22 Suppl 2:S106-S117. Emans JB, Caubet JF, Ordonez CL, et al. The treatment of spine and chest wall deformities with fused ribs by expansion thoracostomy and insertion of vertical expandable prosthetic titanium rib: growth of thoracic spine and improvement of lung volumes. Spine. 2005; 30(17 Suppl):S58-68. Farley FA, Li Y, Jong N, et al. Congenital scoliosis SRS-22 outcomes in children treated with observation, surgery, and VEPTR. Spine (Phila Pa 1976). 2014; 39(22):1868-1874. Flynn JM, Emans JB, Smith JT, et al. VEPTR to treat nonsyndromic congenital scoliosis: a multicenter, mid-term follow-up study. J Pediatr Orthop. 2013; 33(7):679-684.

Gadepalli SK, Hirschl RB, Tsai WC, et al. Vertical expandable prosthetic titanium rib device insertion: does it improve pulmonary function? J Pediatr Surg. 2011; 46(1):77-80. Hell AK, Campbell RM, Hefti F. The vertical expandable prosthetic titanium rib implant for the treatment of thoracic insufficiency syndrome associated with congenital and neuromuscular scoliosis in young children. J Pediatr Orthop B. 2005; 14(4):287-293. Karlin JG, Roth MK, Patil V, et al. Management of thoracic insufficiency syndrome in patients with Jarcho-Levin syndrome using VEPTRs (vertical expandable prosthetic titanium ribs). J Bone Joint Surg Am. 2014; 96(21):e181. Maruyama T, Takeshita K. Surgical treatment of scoliosis: a review of techniques currently applied. Scoliosis. 2008; 3:6. Motoyama EK, Deeney VF, Fine GF, et al. Effects on lung function of multiple expansion thoracoplasty in children with thoracic insufficiency syndrome: a longitudinal study. Spine. 2006; 31(3):284-290. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Questions and Answers about Scoliosis in Children and Adolescents. © 2017. https://www.niams.nih.gov/Health_Info/Scoliosis/default.asp. Accessed March 13, 2026. Ortop Traumatol Rehabil. 2007 Sep-Oct;9(5):459-66. The vertical expandable prosthetic titanium rib (VEPTR) in the treatment of scoliosis and thoracic deformities. Preliminary report. Latalski M1, Fatyga M, Gregosiewicz A. Pediatr Radiol. 2015 Apr;45(4):606-16. doi: 10.1007/s00247-014-3128-4. Epub 2014 Sep 21. Vertical expandable prosthetic titanium rib (VEPTR): a review of indications, normal radiographic appearance and complications. Parnell SE1, Effmann EL, Song K, Swanson JO, Bompadre V, Phillips GS. Scoliosis Research Society. Information about Thoracic Insufficiency Syndrome Treatment. https://www.srs.org/patients-and- families/conditions-and-treatments/parents/scoliosis/thoracic-insufficiency-syndrome. 2019. Accessed March 13, 2026.
Surg Technol Int. 2009 Apr;18:223-9. Vertical expandable prosthetic titanium rib (VEPTR): indications, technique, and management review. Shah SC1, Birknes JK, Sagoo S, Thome S, Samdani AF. U.S. Food and Drug Administration. 510(k) Premarket Notification Database. Vertical Expandable Prosthetic Titanium Rib 510 (k) Advisory Committee Summary. November 2014. https://www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials/pediatricadvisorycommittee/ucm438974.pdf. Accessed March 13, 2026. Waldhausen JH, Redding GJ, Song KM. Vertical expandable prosthetic titanium rib for thoracic insufficiency syndrome: a new method to treat an old problem. J Pediatr Surg. 2007; 42(1):76-80. White KK, Song KM, Frost N, et al. VEPTR growing rods for early-onset neuromuscular scoliosis: feasible and effective. Clin Orthop Relat Res. 2011; 469(5):1335-1341. Specialty-matched clinical peer review. Revision History Company(ies) DATE REVISION EmblemHealth Mar. 13, 2026 Added covered indication of non-specific chest wall defects in children that would be amenable to VEPTR treatment EmblemHealth Mar. 14, 2025 Transferred policy content to individual company branded template ConnectiCare Feb. 2021 ConnectiCare, Inc. has adopted the clinical criteria of its parent corporation EmblemHealth

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