Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pectus excavatum.
Treatment:  Code 21743 Reconstructive repair of pectus excavatum or carinatum; Nuss procedure with thoracoscopy.
The insurer denied coverage for code 21743 Reconstructive repair of pectus excavatum or carinatum; Nuss procedure with thoracoscopy.  
The denial is overturned.
 
According to the documentation submitted, this is a teenager with pectus excavatum. He was seen by a specialist who noted that from when he was last seen the patient has now noted some dizziness and shortness of breath (SOB). The patient has also noted a slight deepening of his chest wall. The provider noted that the Haller index of 2.8 in the past may not accurately characterize the depth of his pectus. He discussed his findings with the patient and his mother, and the decision was made to proceed with Chest computed tomography (CT).  He was seen for follow up where it was noted that repeat CT now showed a Haller index (HI) of 3.4 and with the high likelihood of compression leading to a diminished ability to respond to demands of exercise. The plan for surgical revision of the chest wall was discussed. He was seen again where it was noted that surgical repair of the pectus was now scheduled. The operation was reviewed with the patient and his mother.

The cardiologist noted in a letter that the patient underwent a complete and maximal stress test with breath gas analysis. He noted that although it was stopped because of symptoms, it was a complete test. He noted that symptom provocation is an indication for stress testing. Additionally, he noted that his Respiratory exchange ratio (RER) met maximal criteria, and this was a complete test. An Exercise stress test (EST) with gas analysis was performed and results were included which indicated the maximum volume of oxygen (max V02) was 58% (percent) of predicted with the test being stopped because of chest pain and leg pain. The patient did perform a normal amount of work.

CT of the chest revealed moderate pectus excavatum deformity as evidenced by a Haller index of 3.4 with correction index of 31% and a mass effect of the right sided chambers.

Based upon the information provided, the patient meets criteria for the proposed code 21743 reconstructive repair of pectus excavatum or carinatum; Nuss procedure with thoracoscopy as it is considered medically necessary. This patient presented with a Haller index of greater than 3.25 and complaints of shortness of breath and decreased exercise tolerance with decreased aerobic capacity with mV02 of only 58%, with symptoms of dizziness. Thus, the patient is showing significant impairment from the pectus, which will only get worse, and was found to be a good candidate at this time for repair by his physician. In addition, the cardiologist noted that he did complete the exercise testing as required and that it did show impairment. 

This patient has a Haller index greater than 3.25 and does have on cardiopulmonary exercise test done showing decreased aerobic capacity as noted by his cardiologist. Thus, the patient has indications for the Nuss procedure.

There is medical necessity for the code 21743 reconstructive repair of pectus excavatum or carinatum; Nuss procedure with thoracoscopy. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for code 21743 reconstructive repair of pectus excavatum or carinatum; Nuss procedure with thoracoscopy is substantiated.