Endoscopic strip craniectomy is considered medically necessary and eligible for reimbursement when used in the surgical treatment of craniosynostosis in infants ages 3 to 6 months. Regardless of the approach used, surgical treatment to repair craniosynostosis is considered reconstructive.

Services that do not meet the medical necessity guidelines on this policy will be considered not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Place of Service: Inpatient

Description

Traditionally, open surgery is performed to correct craniosynostosis (i.e., synostotic plagiocephaly) by making an incision on the scalp from ear-to-ear, mobilizing the scalp to expose the skull, and removing and/or reshaping the affected portion of the skull. In some cases, tiny plates and screws are used to fix the bones into proper position. These are frequently made of material that absorbs over time rather than made of metal. Surgery usually takes between three to seven hours, may require a blood transfusion, and involves a hospital stay of three to seven days.

Endoscopic strip craniectomy is a newer, less invasive surgical technique to remove stenosed sutures in order to allow the skull to expand into a normal shape as the brain grows. In order to obtain optimal results, early diagnosis and treatment is paramount. The preferred age for this surgery is 3 months, but the infant should be no older than 6 months. Endoscopic strip craniectomy is performed through one or two small scalp incisions of about 2- to 3- cm each. The point of incision depends on which sutures are affected. The affected suture is opened and the brain is allowed to grow normally. After surgery, the infant wears a custom made cranial orthosis (molding helmet) for 11 to 12 months to guide and constrain the expansion and correction process. Advantages of endoscopic strip craniectomy include, but may not be limited to, less swelling and blood loss, shorter operative time of approximately one hour, and shortened hospital stay with discharge usually occurring the day after surgery.

See Medical Policy O-13 for information on cranial orthosis for plagiocephaly.

NOTE:

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 circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

InterQual® Level of Care Criteria 2010, Acute Care Pediatric, McKesson Health Solutions, LLC

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MacKinnon S, Rogers GF, Gregas M, et al. Treatment of unilateral coronal synostosis by endoscopic strip craniectomy or fronto-orbital advancement: Ophthalmologic findings. J AAPOS. 2009 Apr;13(2):155-60.

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Podda S. Craniosynostosis Management. Medscape Reference, Drugs, Diseases & Procedures. http://emedicine.medscape.com/article/1281182-overview#a30. Accessed June 7, 2011.

Mayo Clinic Staff. Craniosynostosis. Mayo Clinic. May 7, 2011.  http://www.mayoclinic.com/health/craniosynostosis/DS00959. Accessed June 27, 2011.

American Association of Neurological Surgeons (AANS). Craniosynostosis and Craniofacial Disorders. Available at: http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Craniosynostosis%20and%20Craniofacial%20Disorders.aspx. Accessed June 27, 2011.