Does Q79.8 require prior authorization?

No, Q79.8 does not require prior authorization (high confidence). Covered without prior authorization.

`Q79.8`, Other congenital malformations of musculoskeletal system

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Well-documented evidence in the medical record of complications arising from the sternal deformity (e.g., clinical notes documenting symptoms/signs and relationship to deformity).
Echocardiography demonstrating cardiac compression/displacement with decreased cardiac output when cardiac compromise is claimed.
Pulmonary function testing demonstrating total lung capacity (TLC) ≤ 80% of predicted value when lung compression is claimed.
Exercise pulmonary function tests demonstrating objective evidence of exercise intolerance (values below predicted) when exercise intolerance is claimed.

Surgical repair of severe pectus excavatum deformities that cause functional deficit when done for medical reasons in members who meet all of the following criteria:
An electrocardiogram or echocardiogram has been done if a heart murmur or known heart disease is present to define the relationship of the cardiac problem to the sternal deformity;
Well-documented evidence of complications arising from the sternal deformity. Complications include but may not be limited to: cardiac compression, displacement results in decreased cardiac output demonstrated by echocardiography; or Reduced lung capacity as demonstrated by a total lung capacity (TLC) less than or equal to 80% of predictive value per pulmonary function testing; or There is objective evidence of exercise intolerance due to reduced lung capacity as documented by exercise pulmonary [...]
A CT scan of the chest demonstrates a pectus index, derived from dividing the transverse diameter of the chest by the anterior-posterior diameter, greater than 3.25;
Surgical reconstruction of musculoskeletal chest wall deformities (congenital absence or hypoplasia of pectoralis major and minor muscles; congenital partial absence of the upper costal cartilage) associated with Poland's syndrome that cause functional impairment (also see CPB 0185 - Breast Reconstructive Surgery).
CPT codes covered if selection criteria are met for pectus excavatum: 21740, 21742, 21743.

ANTHEM-SURG.00023, Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

AETNA-CPB-0271, Wheelchairs and Power Operated Vehicles (Scooters)

AETNA-CPB-0272, Pectus Excavatum and Poland's Syndrome: Surgical Correction

AETNA-CPB-0582, Titanium Rib

Ask Backwork about documentation requirements, denial risks, or coverage in your state.