Diagnosis: Pectus Carinatum
Treatment: durable medical equipment: spinal orthosis
The insurer denied durable medical equipment: spinal orthosis.
The determination is upheld.

This is a patient with a past medical history (PMH) significant for pectus carinatum. He was previously evaluated by a pediatric surgeon and attempted bracing therapy but patient had concerns about it fitting well. Per the pediatric surgeon's note, the patient notes having occasional chest pain that might be related to injury after working out. The patient is interested in restarting pectus bracing therapy. The patient is seeking approval due to a concern that bracing therapy is necessary due to symptoms and that treatment is not for cosmetic reasons. The surgeon notes no shortness of breath or exercise intolerance. At issue is the medical necessity of durable medical equipment: spinal orthosis.

The spinal orthosis/ pectus carinatum bracing is not medically necessary in this patient's case. Based on medical documentation, he has no shortness of breath or exercise intolerance. Occasional chest pain was not felt by the surgeon to be due to pectus carinatum. The surgeon notes in their assessment that the "carinatum deformity is unlikely to cause any significant physiological problems." Based on the literature, pectus bracing is effective in patients with a compliant and non-stiff chest. This patient has a reported stiff chest wall per the surgeon. Pectus bracing for pectus carinatum has not been shown to be effective in this setting.