CurrentColorado Rocky Mountain Health PlansPolicy 2026T0031GG

Plagiocephaly and Craniosynostosis Treatment

Defines coverage guidance for cranial orthotic devices and related surgical repair for infants with craniosynostosis or positional (nonsynostotic) plagiocephaly under UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPlagiocephaly and Craniosynostosis Treatment

Policy CodePolicy 2026T0031GG

Change TypeOperational revision and template consolidation

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit prior authorization and supporting medical records for cranial orthoses and related surgical repair for review under InterQual CP criteria.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Oxford plan membership and archived previous policy versions 2025T0031FF and SURGERY 114.9.

Class IIFDA classification for cranial orthoses

3–18 moAge range FDA indicates for cranial orthoses

InterQualClinical criteria source

21175Surgical repair code

S1040,L0112,L0113,D5924

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Coverage Criteria

Cranial orthoses coverage

Covered when ALL of the following are met as defined by InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling:

InterQual-based medical necessity: Cranial orthotic devices are considered proven and medically necessary for infants following craniosynostosis surgery or for nonsynostotic (deformational) or positional plagiocephaly when InterQual criteria are met.use InterQual criteria

See InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling for required age, severity, and prior treatment details.

Surgical repair

Surgical repair:

Craniosynostosis surgical repair: Repair of craniosynostosis (CPT 21175) should be evaluated under the Cosmetic and Reconstructive Procedures policy for medical necessity and coverage.refer to related policy

See the Medical Policy titled Cosmetic and Reconstructive Procedures for clinical criteria and coverage determination.

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws. Members and providers should consult the applicable benefit plan for coverage determinations.

The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claim payment. Services that lack documentation demonstrating that plan clinical criteria are met may be denied as not medically necessary.

Applicable Codes

Applicable HCPCS/DentalHCPCS

D5924	Cranial prosthesis
L0112	Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated
L0113	Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment
S1040	Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

Referenced CPTCPT

21175

Surgical treatment to repair craniosynostosis (refer to Cosmetic and Reconstructive Procedures policy)

Provider Actions and Requirements

Prior Authorization

Medical necessity review and potential prior authorization

Coverage is subject to medical necessity review using InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling. Providers should reference the InterQual criteria when submitting requests.

InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling

Note

Provider action highlight

Providers may need to take specific actions (submit supporting documentation, confirm benefit eligibility, or obtain prior authorization) to avoid delays or denials. Confirm member-specific benefits before ordering.

Documentation Required

Medical records may be required

Background

Cranial orthotic devices are considered proven and medically necessary for treating infants following surgical repair of craniosynostosis and for infants with nonsynostotic (deformational/positional) plagiocephaly when clinical criteria are met. The FDA classifies cranial orthoses as Class II devices intended to apply pressure to prominent regions of an infant's cranium to improve cranial symmetry in infants typically aged 3 to 18 months. Coverage decisions should follow the InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling criteria for specific age, severity, and prior treatment requirements.

Definitions

Cranial orthosis — Definition and FDA class/age details

FDA classificationClass II device (special controls including prescription use, biocompatibility testing, and labeling requirements)

FDA-indicated age rangeInfants from 3 to 18 months of age

Intended useApply pressure to prominent regions of an infant's cranium to improve cranial symmetry and/or shape for moderate to severe nonsynostotic positional plagiocephaly

Regulatory product code referenceProduct code MVA (see FDA PMN database)

Clinical coverage referenceMedical necessity criteria defined by InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling

Craniosynostosis — Definition and surgical/orthosis note