HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
O-13-025
Topic:
Cranial Orthosis for Plagiocephaly
Section:
Orthotic & Prosthetic Devices
Effective Date:
November 6, 2017
Issued Date:
March 4, 2019
Last Revision Date:
February 2019
Annual Review:
February 2019
 
 

A cranial orthosis used in the treatment of plagiocephaly is a device intended for medical purposes to apply pressure to prominent regions of an infant's cranium in order to improve cranial symmetry and/or shape.

Policy Position

Non-synostotic Plagiocephaly

Cranial orthotic devices used in the treatment of moderate-to-severe non-synostotic plagiocephaly may be considered medically necessary when ALL of the following criteria are met:

  • The infant must have tried and failed conservative therapy (i.e., repositioning) for a minimum of two (2) months; and
  • The infant must be 3 - 18 months of age; and
  • Cranial asymmetry is documented by EITHER of the following:
    • Moderate to severe plagiocephaly in ONE of the following anthropometric dimensions (Table 1):
      • Cranial vault; or
      • Cranial base; or
      • Orbitotragial depth; or
    • Cephalic index measurement is two (2) standard deviations above or below the mean (Table 2).

Cranial orthosis is considered cosmetic and therefore non-covered when used in the treatment of non-synostotic plagiocephaly with mild deformity and/or when a minimum trial period of two (2) months of conservative therapy has not been tried. 

Cranial orthotic devices for non-synostotic plagiocephaly for all other indications is considered not medically necessary.

L0112

L0113

S1040  

 

 

 

 




Synostotic Plagiocephaly
Cranial orthotic devices used in the post-operative treatment of synostotic plagiocephaly may be considered medically necessary for infants with moderate to severe residual plagiocephaly after surgical correction when cranial asymmetry is documented by ANY of the following:

  • Moderate to severe plagiocephaly in ONE of the following anthropometric dimensions (Table 1):
    • Cranial vault; or
    • Cranial base; or
    • Orbitotragial depth; or
  • Cephalic index measurement is two (2) standard deviations above or below the mean (Table 2). 

Cranial orthotic devices for synostotic plagiocephaly for all other indications is considered not medically necessary.

L0112

L0113

S1040  

 

 

 

 




Related Policies

Refer to Medical Policy E-1 Durable Medical Equipment (DME) for additional information.


Covered Diagnosis Codes for Procedure Codes L0112, L0113 and S1040

Q67.3

Q75.0

Q75.8

 

 

 

 



Place of Service: Outpatient

Cranial orthosis for plagiocephaly is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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