Mountain State Medical Policy Bulletin
Section: Orthotic & Prosthetic Devices
Number: O-13
Topic: Cranial Orthosis for Plagiocephaly
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Cranial orthotic devices (S1040) used in the treatment of non-synostotic plagiocephaly (754.0) are eligible for reimbursement when ALL of the following criteria are met:

  1. The infant must have tried and failed conservative therapy (i.e., repositioning) for a minimum of two months.
  2. The infant must be 3 - 18 months of age.
  3. The infant must have moderate to severe deformity due to non-synostotic positional plagiocephaly.
Cranial orthosis is considered cosmetic when used in the treatment of non-synostotic plagiocephaly with mild deformity and/or when a minimum trial period of two months of conservative therapy has not been tried. Therefore, these services are not covered. A participating, preferred, or network provider can bill the member for the denied service.

When reported as a treatment for synostotic plagiocephaly (Craniosynostosis)(756.0), both the helmet (S1040) and the band (S1040) are considered experimental/investigational, and, therefore, are not covered. A participating, preferred, or network provider can bill the member for the denied service. Use of this device in the treatment of synostotic plagiocephaly does not have FDA approval.

NOTE:
A cranial helmet (L0100, L0110) used as a protection device following surgery is eligible.

Coverage for Prosthetics and Orthotics is determined according to individual or group customer benefits.

Description

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. Orthotic cranioplasty has been primarily researched as a non-invasive treatment of non-synostotic plagiocephaly. It involves the use of a custom-molded orthotic, either a band or a helmet, to mold the shape of the cranium. Cranial orthotic devices include, but are not limited to, Dynamic Orthotic Cranioplasty (DOC) Band, OPI Band, Hanger Cranial Band, Star Band, and CranioCap.

Plagiocephaly refers to an asymmetrically shaped head. Synostotic plagiocephaly describes an asymmetrically shaped head due to premature closure of the sutures of the cranium. Non-synostotic plagiocephaly, also called positional plagiocephaly, occurs when the sutures remain open. This condition can be secondary to various environmental factors including, but not limited to: premature birth, restrictive intrauterine environment, birth trauma, torticollis, cervical anomalies, and sleeping position.


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.

Procedure Codes

L0100L0110S1040   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

12/1999, Dynamic Orthotic Cranioplasty (DOC)
10/2001, Cranial orthosis for plagiocephaly
02/2002, Cranial orthoses procedure codes changed

References

Consortium Health Plans, Inc.

Analysis of Posterior Plagiocephaly: Deformational vs. Synostotic, Plastic and Reconstructive Surgery, Vol. 103, No. 2, February 1999

Cranial Growth Unrestricted During Treatment of Deformational Plagiocephaly, Pediatric Neurosurg 1999, Vol. 30

Long-Term Developmental Outcomes in Patients with Deformational Plagiocephaly, Pediatrics, Vol. 105, No. 2, February 2000

Dynamic Orthotic Cranioplasty: Treatment of the Older Infant, Neurosurg Focus, Vol. 9, September 2000

Dynamic Orthotic Cranioplasty as a Treatment of Plagiocephaly, Medical Policy Reference Manual, Policy 1.01.11, 07/12/2002

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Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

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