CurrentBlue Cross Blue Shield of VermontPolicy 1.01.VT11

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

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This policy governs medical necessity, prior approval, coding, and coverage criteria for adjustable cranial orthoses used in pediatric individuals with postsurgical craniosynostosis or persistent positional plagiocephaly or brachycephaly without synostosis. Benefits remain subject to the member’s applicable contract or benefit plan.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAdjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

Policy CodePolicy 1.01.VT11

Change TypeAdministrative/reference update only

Effective DateJan 1, 2027

Last ReviewSep 1, 2026

Next Review DateAug 1, 2027

Key ActionObtain prior approval before providing the service.

SourceLink

POLICY UPDATE CHANGES

The September 2026 policy review updated the reference resource without changing the policy statement.

3–18 moCoverage age range

2 moRequired repositioning therapy

6 mmSkull-base asymmetry threshold

8 mmCranial-vault asymmetry threshold

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CurrentBlue Cross Blue Shield of VermontPolicy 1.01.VT11

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

Customize your policy alerts

Sign up for bcbsvermont Policy 1.01.VT11 alerts

Get alerted when Policy 1.01.VT11 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAdjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

Policy CodePolicy 1.01.VT11

Change TypeAdministrative/reference update only

Effective DateJan 1, 2027

Last ReviewSep 1, 2026

Next Review DateAug 1, 2027

Key ActionObtain prior approval before providing the service.

SourceLink

POLICY UPDATE CHANGES

The September 2026 policy review updated the reference resource without changing the policy statement.

3–18 moCoverage age range

2 moRequired repositioning therapy

6 mmSkull-base asymmetry threshold

8 mmCranial-vault asymmetry threshold

4 mmOrbitotragal asymmetry threshold

InvestigationalOther indications

Medical Necessity and Coverage Criteria

Postsurgical craniosynostosis

May be considered medically necessary as part of post-operative management.

Postsurgical craniosynostosis: The individual has craniosynostosis and the adjustable cranial orthosis is used as part of post-operative management.

Persistent plagiocephaly or brachycephaly without synostosis

May be considered medically necessary when ALL of the following conditions have been met.

Age: The individual is at least 3 months of age but not greater than 18 months of age.3–18 months
Conservative therapy: Asymmetry has not been substantially improved following at least 2 months of cranial repositioning therapy, with or without physical therapy.At least 2 months
Due to the mobility of individuals older than 4 months, repositioning therapy is not effective and a trial is not indicated.
Qualifying cranial asymmetry
- Cephalic index: The cephalic index is at least 2 standard deviations above or below the mean for the appropriate gender and age.≥ +2 SD or ≤ −2 SD
  See the policy’s Table 1 normative values.
- Skull base asymmetry: The right/left discrepancy measured subnasally to the tip of the tragus is at least 6 mm.≥ 6 mm
- Cranial vault asymmetry: The right/left discrepancy measured from the frontozygomaticus point to the contralateral euryon is at least 8 mm.≥ 8 mm
- Orbitotragal asymmetry:

Second helmet or band

A second helmet or band may be approved when the initial-device criteria were met.

Persistent or insufficiently improved asymmetry: Asymmetry has not resolved or significantly improved after 2–4 months of the initial custom molded orthotic.2–4 months
Initial criteria met: The individual met the medical-necessity criteria for the initial helmet or band.

Investigational indications

The service is considered investigational.

Other indications: Use of an adjustable cranial orthosis for all indications not outlined in the policy is investigational.

Codes and Clinical Measurements

Covered HCPCS CodesHCPCSCovered

L0112	Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated.
L0113	Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment.
S1040	Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s).

Covered ICD-10-CM CodesICD-10Covered

Q67.3	Plagiocephaly
Q75.001	Craniosynostosis unspecified, unilateral
Q75.002	Craniosynostosis unspecified, bilateral
Q75.009	Craniosynostosis unspecified
Q75.01	Sagittal craniosynostosis
Q75.021	Coronal craniosynostosis unilateral
Q75.022	Coronal craniosynostosis bilateral
Q75.029	Coronal craniosynostosis unspecified
Q75.03	Metopic craniosynostosis
Q75.041	Lambdoid craniosynostosis, unilateral

1–10 of 16

1/2

Cephalic Index

Qualifying thresholdAt least 2 standard deviations above or below the mean

Comparison standardThe applicable normative mean and standard deviation for the individual’s gender and age

Clinical useUsed to assess abnormal head shapes without asymmetry

Skull Base Asymmetry

Qualifying thresholdAt least 6 mm right/left discrepancy

MeasurementMeasured subnasally to the tip of the tragus

Qualifying role

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Approval and Complete Authorization Required

Prior approval is required for an adjustable cranial orthosis. Benefits remain subject to all terms, limitations, and conditions of the member’s subscriber contract.

Verify member-specific benefits, exclusions, and applicable contract provisions before providing the service.
An authorization request that is incomplete or missing required policy information may delay the coverage decision pending submission of the missing information.

Step Therapy

Document Conservative Repositioning Therapy

For persistent plagiocephaly or brachycephaly without synostosis, document that asymmetry was not substantially improved after at least 2 months of cranial repositioning therapy, with or without physical therapy. Due to mobility after 4 months of age, repositioning therapy is generally not effective; therefore, a trial is not indicated for individuals older than 4 months.

Document the therapy type and duration in the authorization request.

Clinical Background

An adjustable cranial orthosis is a helmet or band that progressively molds an infant’s cranial shape by applying corrective forces to prominent areas while allowing growth in adjacent flattened areas. It may be used for postsurgical craniosynostosis or persistent positional plagiocephaly or brachycephaly without synostosis.

Measurement Definitions

Cephalic Index

DefinitionThe maximum head width divided by head length, expressed as a percentage

Width landmarkWidth is measured between the most lateral points of the head in the parietal region, called the euryon

Length landmarksLength is measured from the glabella to the opisthocranion

Skull Base Asymmetry

DefinitionThe right/left discrepancy measured from the subnasal point to the tip of the tragus

Starting landmarkSubnasal point

Ending landmark

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAdjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

Policy CodePolicy 1.01.VT11

Change TypeAdministrative/reference update only

Effective DateJan 1, 2027

Last ReviewSep 1, 2026

Next Review DateAug 1, 2027

Key ActionObtain prior approval before providing the service.

SourceLink

On This Page

The right/left asymmetry measured from the lateral aspect of the orbit to the tip of the ipsilateral tragus is at least 4 mm.

One of the cranial asymmetry measurements that may establish medical necessity

Cranial Vault Asymmetry

Qualifying thresholdAt least an 8 mm right/left discrepancy

MeasurementMeasured from the frontozygomaticus point to the contralateral euryon

Qualifying roleOne of the cranial asymmetry measurements that may establish medical necessity

Orbitotragal Asymmetry

Qualifying thresholdAt least a 4 mm right/left asymmetry

MeasurementMeasured from the lateral aspect of the orbit to the tip of the ipsilateral tragus

Qualifying roleOne of the cranial asymmetry measurements that may establish medical necessity

Device Duration

Initial device duration2–4 months

Device descriptionThe custom molded orthotic is designed to fit the individual’s head for 2–4 months

Second device considerationA second helmet or band may be required if the asymmetry has not resolved or significantly improved after 2–4 months

Post-operative management of craniosynostosis may be medically necessary without this positional-deformity therapy requirement.

Unsupported block type: documentation

Unsupported block type: denial_risk

Denial Risk

Failure to Meet Positional Deformity Criteria

Coverage for positional plagiocephaly or brachycephaly may be denied when the individual does not meet the policy’s age, conservative-therapy, or measurement requirements.

Age is outside the range of at least 3 months through not more than 18 months.
Asymmetry substantially improved without the required documented therapy, or the required therapy duration is not documented.
No qualifying measurement is documented: cephalic index at least 2 standard deviations above or below the age- and gender-appropriate mean; skull base asymmetry of at least 6 mm; cranial vault asymmetry of at least 8 mm; or orbitotragal asymmetry of at least 4 mm.

Documentation Required

Avoid an Incomplete Authorization Request

Submit a complete authorization request before providing the service. Missing information may delay the decision while the plan requests the documentation needed to apply the policy guidelines.

Include diagnosis, age, conservative-therapy history, device history when requesting a second device, and qualifying cranial measurements.
Verify benefits because coverage may vary by member contract, group, ASO arrangement, NEHP/ABNE or FEP enrollment, and applicable exclusions; member contract language takes precedence when it conflicts with the policy.

Tip of the tragus, the cartilaginous projection of the auricle at the front of the ear

Cranial Vault Asymmetry

DefinitionThe right/left discrepancy measured from the frontozygomaticus point to the contralateral euryon

Starting landmarkFrontozygomaticus point, identified by palpation of the suture line above the upper outer corner of the orbit

Ending landmarkContralateral euryon, the most lateral point on the head in the parietal region

Orbitotragal Asymmetry

DefinitionThe right/left difference in orbitotragal distances

Starting landmarkLateral aspect of the orbit

Ending landmarkTip of the ipsilateral tragus