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    v1.0.31
    OpenPayerPolicy UpdatesOrthopedics/MusculoskeletalRegence VEPTR Coverage Criteria 2026 | OpenPayer
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    CurrentRegencePolicy 159

    Vertical Expandable Prosthetic Titanium Rib

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    Coverage of VEPTR use, including expansion, for infants and children with progressive thoracic insufficiency syndrome caused by rib or chest wall defects; other indications, including scoliosis without thoracic insufficiency, are investigational.

    Policy Summary
    PayerRegence
    PolicyVertical Expandable Prosthetic Titanium Rib
    Policy CodePolicy 159
    Change TypeNo material change
    Effective DateSeptember 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateMay 1, 2027
    Key ActionSubmit history and physical examination or chart notes documenting the syndrome, its cause, the patient's age, and skeletal maturity.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6 months–skeletal maturityMedically necessary age range
    1Covered clinical indication
    InvestigationalOther indications
    4–6 monthsDevice expansion interval
    30

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    References cited

    Medical Necessity and Investigational Status

    Medically Necessary

    May be considered medically necessary when the following condition is met.

    Medically necessary VEPTR use: Use of the vertical expandable prosthetic titanium rib, including expansion, for treatment of progressive thoracic insufficiency syndrome due to rib and/or chest wall defects in an infant or child between six months of age and skeletal maturity.Age >= 6 months and through skeletal maturity

    The syndrome must be progressive and caused by rib and/or chest wall defects.

    Investigational

    Considered investigational when any of the following applies.

    Investigational VEPTR use: Use of the vertical expandable prosthetic titanium rib for any condition other than qualifying progressive thoracic insufficiency syndrome due to rib and/or chest wall defects, including treatment of scoliosis in a patient without thoracic insufficiency.Any condition other than qualifying progressive thoracic insufficiency syndrome

    Scoliosis without thoracic insufficiency is specifically included.

    Medically Necessary

    VEPTR may be considered medically necessary when all of the following are met.

    Medically necessary VEPTR use

    • Clinical indication: The patient has progressive thoracic insufficiency syndrome due to rib and/or chest wall defects.Progressive thoracic insufficiency syndrome due to rib and/or chest wall defects
    • Age and developmental status: The patient is at least six months of age and skeletally immature.At least six months of age and before skeletal maturity

    Investigational / Not Covered

    VEPTR is investigational for all other indications.

    Investigational indications

    • Scoliosis without thoracic insufficiency: Treatment of scoliosis in a patient without thoracic insufficiency.Scoliosis without thoracic insufficiency
    • Other conditions: Any indication other than progressive thoracic insufficiency syndrome due to rib and/or chest wall defects.All other indications

    VEPTR use for all other indications is considered investigational, including, but not limited to, treatment of scoliosis in patients without thoracic insufficiency. The policy does not identify sufficient research or research-based clinical guideline support for these uses.

    Coding and Eligibility Parameters

    CPT CodesCPT
    20999Unlisted procedure, musculoskeletal system, general
    21899Unlisted procedure, neck or thorax
    22899Unlisted procedure, spine
    Minimum age
    Minimum ageAt least six months of age
    Covered populationInfants and children at least six months of age
    Age boundaryUse in patients younger than six months is outside the medically necessary criteria
    Skeletal maturity
    Developmental statusThe child must be skeletally immature
    Upper boundaryCoverage extends through skeletal maturity
    Covered age range

    Documentation and Review Considerations

    Documentation Required

    Required Clinical Records

    Submit the clinical records needed for review of VEPTR, including the patient’s history and physical examination, chart notes, documentation of progressive thoracic insufficiency syndrome, and evidence of its cause.

    • History and physical examination
    • Chart notes
    • Documentation of progressive thoracic insufficiency syndrome
    • Evidence of the cause, including age and skeletal maturity
    Denial Risk

    Investigational Indication

    VEPTR use for conditions other than progressive thoracic insufficiency syndrome due to rib and/or chest wall defects is considered investigational, including treatment of scoliosis in patients without thoracic insufficiency.

    Clinical Background

    VEPTR is a rib-based growth-sparing device used in skeletally immature children to stabilize and shape the thoracic cavity while allowing continued growth. It is used in the setting of thoracic insufficiency syndrome, which is the inability of the thorax to support normal respiration or lung growth. Thoracic insufficiency may be associated with severe rib or chest wall defects, rib fusion, scoliosis, or hypoplastic thorax syndromes.

    Progressive thoracic insufficiency may involve respiratory insufficiency, reduced chest wall mobility, worsening three-dimensional thoracic deformity, declining pulmonary function, supplemental oxygen use, or mechanical ventilation. Implantation should be performed in specialized centers with multidisciplinary preoperative evaluation.

    Key Definitions

    Thoracic insufficiency syndrome (TIS)
    DefinitionThoracic insufficiency syndrome is the inability of the thorax to support normal respiration or lung growth.
    Respiratory functionThe condition affects the thorax’s ability to support normal breathing.
    Growth functionThe condition affects the thorax’s ability to support normal lung growth.
    Progressive thoracic insufficiency syndrome
    Respiratory featureRespiratory insufficiency may occur as the syndrome progresses.
    Chest wall featureLoss of chest wall mobility may occur.
    Structural feature
    Policy Summary
    PayerRegence
    PolicyVertical Expandable Prosthetic Titanium Rib
    Policy CodePolicy 159
    Change TypeNo material change
    Effective DateSeptember 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateMay 1, 2027
    Key ActionSubmit history and physical examination or chart notes documenting the syndrome, its cause, the patient's age, and skeletal maturity.
    SourceLink
    On This Page
    Medical Necessity and Investigational StatusCoding and Eligibility ParametersDocumentation and Review ConsiderationsClinical BackgroundKey Definitions
    At least six months of age through skeletal maturity
    Denial Risk

    Age Outside Policy Criteria

    VEPTR is intended for infants and children from six months of age through skeletal maturity. Use in patients younger than six months falls outside the policy criteria.

    • Covered age range: six months of age through skeletal maturity
    • Younger than six months: outside policy criteria
    Documentation Required

    Insufficient Clinical Documentation

    If the required clinical documentation is not submitted, Regence may be unable to determine whether the policy criteria are met, which could affect the review and decision outcome.

    • Submit history and physical examination and chart notes
    • Submit documentation of the syndrome and evidence of its cause, including age and skeletal maturity
    Denial Risk

    Noncovered or Investigational Indication

    VEPTR use for all other indications is noncovered under the policy and considered investigational because there is insufficient research showing improved health outcomes and no research-based clinical guidelines recommending its use for those conditions.

    • Includes scoliosis in patients without thoracic insufficiency
    • Noncovered or investigational use may result in denial
    Worsening three-dimensional thoracic deformity may occur.
    Pulmonary featurePulmonary function tests may worsen.
    Vertical expandable prosthetic titanium rib (VEPTR)
    DeviceVEPTR is a curved rod used to stabilize and shape the thoracic cavity.
    PlacementIt may be positioned between the ribs.
    Alternative placementIt may be positioned between the ribs and either the spine or pelvis.
    Policy-specific TIS indication
    Qualifying conditionProgressive thoracic insufficiency syndrome due to rib and/or chest wall defects
    Pediatric populationInfants and children at least six months of age who are skeletally immature
    Developmental rangeThe covered population extends from six months of age through skeletal maturity