HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
O-13-030
Topic:
Cranial Orthosis for Plagiocephaly
Section:
Orthotic & Prosthetic Devices
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
April 2023
 
 

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 three (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 (SD) above or below the mean (Table 2).

Cranial orthotic devices for non-synostotic plagiocephaly not meeting the criteria as indicated in this policy is considered not medically necessary.

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 (SD) above or below the mean (Table 2). 

Cranial orthotic devices for synostotic plagiocephaly not meeting the criteria as indicated in this policy is considered not medically necessary.

S1040

 

 

 

 

 

 




Determination of Severity of Plagiocephaly

Determination of the severity of plagiocephaly requires precise measurements of the skull using either the cephalic index or anthropomorphic measurements.

Table 1

Specifications for Taking Anthropometric Measurements

 

Comparative Cranial Landmarks

Cranial Vault

Left frontozygomatic point (fz) to right euryon (eu) minus right frontozygomatic point (fz) to left euryon (eu)

Cranial Base

Subnasal point (sn) to left tragus (t) minus subnasal pint (sn) to right tragus (t)

Orbitotragial Depth

Left exocanthion point (ex) to left tragus (t) minus right exocanthion point (ex) to right tragus (t)

Moderate to severe plagiocephaly is defined as one of the following:

  • Cranial base (sn – t): >= 6 mm difference between left and right measurements
  • Cranial vault (fz – contralateral eu): >= 8 mm difference between left and right measurements
  • Obitotragial depth (ex – t): >= 4 mm difference between left and right measurements.

 

Table 2

 Cephalic index: Head width (eu-eu) x 100

              Head length (g-op)

Moderate to severe plagiocephaly is defined as a cephalic index two standard deviations above or below the mean. Infants with deformational scaphocephaly will have a lower cephalic index due to a very long and narrow skull deformity. Infants with deformational brachycephaly will have an increased cephalic index due to a very wide and short skull deformity.

Gender

Age

-2SD

-1SD

Mean

+1SD

+2SD

Male

16 days - 6 months

63.7

68.7

73.7

78.7

83.7

 

 

6 – 12 months

64.8

64.8

78

84.6

91.2

Female

16 days - 6 months

63.9

63.9

73.3

78

82.7

 

 

6 – 12 months

69.5

69.5

78.5

83

87.5

Assessment of plagiocephaly may be based on anthropomorphic measures of the head, using anatomical and bony landmarks. However, there is no accepted minimum objective level of asymmetry for a plagiocephaly diagnosis. The following table presents normative values and the mean pretreatment asymmetries reported in large case series. These may be useful in determining if a significant variation from normal is present.


Related Policies

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


Covered Diagnosis Codes for Procedure Code S1040

M95.2

Q67.3

Q67.4

Q75.001

Q75.002

Q75.009

Q75.01

Q75.021

Q75.022

Q75.029

Q75.03

Q75.041

Q75.042

Q75.049

Q75.051

Q75.052

Q75.058

Q75.08

Q75.8

Q75.9

 



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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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.