CurrentEmblemHealthPolicy MG.MM.SU.67a

Vertical Expandable Prosthetic Titanium Rib

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Governs medical necessity and coverage criteria for use of the Vertical Expandable Prosthetic Titanium Rib (VEPTR) in infants and children with thoracic insufficiency syndrome or rib/chest wall defects, for EmblemHealth members.

Policy Summary

PayerEmblemHealth

PolicyVertical Expandable Prosthetic Titanium Rib

Policy CodePolicy MG.MM.SU.67a

Change TypeAdded covered indication

Effective Date

Last ReviewMar 13, 2026

Next Review DateMar 13, 2026

Key ActionSubmit preauthorization with clinical evidence demonstrating the member meets the criteria for VEPTR.

SourceLink

POLICY UPDATE CHANGES

Added covered indication of non-specific chest wall defects in children that would be amenable to VEPTR treatment.

6 months–skeletal maturityAge range

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CurrentEmblemHealthPolicy MG.MM.SU.67a

Vertical Expandable Prosthetic Titanium Rib

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Policy Summary

PayerEmblemHealth

PolicyVertical Expandable Prosthetic Titanium Rib

Policy CodePolicy MG.MM.SU.67a

Change TypeAdded covered indication

Effective Date

Last ReviewMar 13, 2026

Next Review DateMar 13, 2026

Key ActionSubmit preauthorization with clinical evidence demonstrating the member meets the criteria for VEPTR.

SourceLink

POLICY UPDATE CHANGES

Added covered indication of non-specific chest wall defects in children that would be amenable to VEPTR treatment.

6 months–skeletal maturityAge range

Coverage and Medical Necessity Criteria

Medically Necessary Indications

VEPTR is considered medically necessary when ALL of the following are met:

Age and diagnosis: Patient is between 6 months of age and skeletal maturity AND has progressive thoracic insufficiency syndrome due to rib and/or chest wall defectsage: 6 months to skeletal maturity

Includes TIS as defined in definitions

Underlying conditions: Rib/chest wall defects may be secondary to one or more of the following: congenital scoliosis; neuromuscular scoliosis; infantile and juvenile idiopathic scoliosis; syndromic scoliosis; or non-specific chest wall defects amenable to VEPTR treatment

Enumerated etiologies listed in policy

Use of VEPTR for any condition other than those specifically listed as medical indications in this policy — including Poland Syndrome — is not considered medically necessary due to insufficient evidence of therapeutic value.

Use of VEPTR solely as a treatment for scoliosis when Thoracic Insufficiency Syndrome (TIS) or risk for TIS is not present is not considered medically necessary.

Procedure and Diagnosis Codes

Procedure CodesCPT

20999	Unlisted procedure, musculoskeletal system, general.
21899	Unlisted procedure, neck or thorax.

Diagnosis CodesICD-10

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

1–10 of 27

1/3

Cobb angle thresholds — inv-06

Scoliosis diagnostic thresholdCobb angle ≥ 10° defines scoliosis.

Significant progressionAn increase in Cobb angle ≥ 5° is regarded as a significant change indicative of progression.

Severe in skeletally immature persons>45° Cobb angle is considered severe in skeletally immature persons.

Preauthorization, Documentation, and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. The treating physician or primary care provider must submit clinical evidence demonstrating that the member meets the criteria for the procedure to be performed. Include applicable procedure codes when requesting prior authorization; unlisted CPT codes should be noted as such and accompanied by supporting documentation.

Submit prior authorization request before the procedure when possible
Include listed procedure codes or indicate unlisted CPT with supporting documentation
Attach all relevant clinical records, imaging, and physician notes

Documentation Required

Clinical Evidence Submission

The treating physician or primary care provider must submit the clinical evidence that the member meets the clinical review criteria. This evidence should document the diagnosis (for example, progressive thoracic insufficiency syndrome due to rib and/or chest wall defects), age eligibility (e.g., between 6 months and skeletal maturity), and any underlying scoliosis condition or chest wall defect that supports VEPTR treatment.

Key Terms and Definitions

VEPTR — inv-12

Device nameVertical Expandable Prosthetic Titanium Rib (VEPTR)

DescriptionCurved rod placed horizontally in the chest to shape the thoracic cavity for treatment of spinal and thoracic deformities.

Regulatory noteFDA CDRH cleared the VEPTR‑VEPTR II device in 2014 for use in skeletally immature patients with severe, progressive spinal deformities and/or three‑dimensional thoracic deformity associated with or at risk of Thoracic Insufficiency Syndrome (TIS).

Thoracic Insufficiency Syndrome (TIS) — inv-13

DefinitionThoracic Insufficiency Syndrome (TIS) is the inability of the thorax to support normal respiration or lung growth.

Included conditionsMay include flail chest, hypoplastic thorax syndromes, and rib fusion with scoliosis.

Background

The Vertical Expandable Prosthetic Titanium Rib (VEPTR) is an expandable curved titanium rod implanted horizontally along the chest to modify thoracic shape and volume. It is used in skeletally immature patients to manage deformities that impair thoracic function and lung development, most commonly in the setting of Thoracic Insufficiency Syndrome (TIS), which describes the inability of the thorax to support normal respiration or lung growth.

Clinically, VEPTR is intended to restore or preserve thoracic volume and to control progressive spinal and chest wall deformity in children with fused ribs, hypoplastic thoraces, flail chest, or progressive scoliosis associated with TIS. The device is typically considered for patients between 6 months of age and skeletal maturity when progressive deformity threatens respiratory function or thoracic growth.

Revision History and Policy Changes

2026-03-13material_changeLatest

Added covered indication for non-specific chest wall defects in children amenable to VEPTR treatment.

2025-03-14administrative_update

Transferred policy content to individual company branded template.

2021-02adoption