Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses Corporate Medical Policy

Prior Approval Required

Prior approval is required before providing an adjustable cranial orthosis. Benefits remain subject to the member’s subscriber contract, including its limitations, conditions, exclusions, and applicable group or individual terms; contract language takes precedence when it conflicts with this policy.

• Submit the authorization request with the policy-required clinical documentation.
• An incomplete request may delay the coverage decision until missing information is submitted.

Document Failed Repositioning Therapy

Document that the individual completed conservative cranial repositioning therapy for at least 2 months, with or without physical therapy, and that the asymmetry was not substantially improved.

• For individuals older than 4 months, repositioning therapy is generally not effective because of increased mobility; therefore, a repositioning trial is not indicated for this age group.

Cranial Measurement Documentation

Include objective cranial measurements supporting asymmetry. At least one qualifying measurement must be documented, with the measurement method and relevant clinical records.

• Cephalic Index: at least 2 standard deviations above or below the mean for the individual’s age and gender. The index is maximum head width between the lateral parietal points (euryon) divided by head length from the glabella to the opisthocranion, expressed as a percentage; compare with age- and gender-specific norms. Table 1 norms include: males, 16 days–6 months, −2 SD 63.7 and +2 SD 83.7; males, 6–12 months, −2 SD 64.8 and +2 SD 91.2; females, 16 days–6 months, −2 SD 63.9 and +2 SD 82.7; females, 6–12 months, −2 SD 69.5 and +2 SD 87.5.
• Skull-base asymmetry: at least 6 mm right/left discrepancy measured subnasally to the tip of the tragus.
• Cranial-vault asymmetry: at least 8 mm right/left discrepancy measured from the frontozygomaticus point to the contralateral euryon.
• Orbitotragal asymmetry: at least 4 mm right/left asymmetry measured from the lateral aspect of the orbit to the tip of the ipsilateral tragus.

Noncovered Indications May Be Investigational

An adjustable cranial orthosis is considered investigational for indications not specifically outlined as medically necessary in this policy.

• Do not assume coverage for indications outside post-operative craniosynostosis management or the defined persistent plagiocephaly/brachycephaly criteria without confirming the member’s applicable benefit.

Initial-Therapy Criteria Not Met

Coverage may be denied when any required initial-therapy criterion is absent or cannot be documented.

• The individual is younger than 3 months or older than 18 months for nonsynostotic plagiocephaly or brachycephaly.
• At least 2 months of cranial repositioning therapy, with or without physical therapy, was not completed when indicated.
• The asymmetry substantially improved after conservative therapy.
• Required cranial measurements are absent or do not meet a qualifying threshold: cephalic index at least 2 standard deviations outside the age- and gender-specific mean, skull-base discrepancy at least 6 mm, cranial-vault discrepancy at least 8 mm, or orbitotragal asymmetry at least 4 mm.
• The diagnosis, indication, measurement method, or other required clinical documentation is missing.

Replacement Orthosis Criteria Not Met

A second helmet or band may be denied when the initial orthosis criteria were not met or when persistent asymmetry after the initial device is not documented.

• The record does not establish that the initial helmet or band met the policy’s qualifying criteria.
• The asymmetry resolved or significantly improved after the initial 2–4 month period.
• Persistent asymmetry after 2–4 months is not documented.

Incomplete Requests Can Delay Decisions

Incomplete authorization requests may delay the decision while the plan awaits missing information. Ensure the request is complete under the policy guidelines before submission.

• Include the diagnosis and indication, age, conservative-therapy history and response, qualifying cranial measurements with methods, and documentation supporting any request for a second orthosis.