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.
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:
Cranial orthotic devices for non-synostotic plagiocephaly not meeting the criteria as indicated in this policy is considered not medically necessary.
S1040 |
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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:
Cranial orthotic devices for synostotic plagiocephaly not meeting the criteria as indicated in this policy is considered not medically necessary.
S1040 |
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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:
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.
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 |
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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)
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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:
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.
