Covered without prior authorization (high confidence)
Documentation Required
Documentation of diagnosis of thoracic insufficiency syndrome (TIS) and clinical findings supporting TIS (e.g., inability of the thorax to support normal respiration or lung growth, description of the mechanism such as fused ribs/hemithorax hypoplasia).
Documentation that the patient is skeletally immature (e.g., growth/age documentation, bone age, or other clinical evidence of skeletal immaturity).
If using an ICD-10 code listed in the policy, documentation that the listed condition 'results in thoracic insufficiency syndrome' (i.e., explicit linkage between ICD-10 diagnosis and TIS).
Documentation that selection criteria referenced by the policy have been met (policy references 'selection criteria' for covered ICD-10 codes but does not list them verbatim).
Key Coverage Criteria
Treatment of thoracic insufficiency syndrome (TIS) in skeletally immature persons (Aetna considers VEPTR medically necessary for this indication).
Flail chest syndrome resulting in thoracic insufficiency syndrome.
Rib fusion and scoliosis resulting in thoracic insufficiency syndrome.
Hypoplastic thorax syndromes resulting in thoracic insufficiency syndrome, including but not limited to achondroplasia, Ellis van Creveld syndrome, Jarcho-Levin syndrome, and Jeune's syndrome.
Scoliosis (if resulting in thoracic insufficiency syndrome) — ICD-10 M41.00–M41.9 (covered if selection criteria are met).
Acquired deformity of chest and rib (if resulting in thoracic insufficiency syndrome) — ICD-10 M95.4 (covered if selection criteria are met).
Clinical documentation demonstrating absence of contraindications listed by the FDA and cited in the policy: presence of proximal ribs adequate for attachment, adequate diaphragmatic function, adequate soft tissue coverage, adequate bone strength for attachment, absence of operative-site infection, and no known allergy to device materials.
If applicable, documentation of pre-operative management when used (e.g., 6-week pre-operative halo traction when performed) and rationale for VEPTR vs. alternative therapies.