CurrentExcellus Health Plan IncPolicy 1.01.32

Cranial Orthotics

Customize your policy alerts

Sign up for excellus_health_plan_inc Policy 1.01.32 alerts

Get alerted when Policy 1.01.32 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs coverage of cranial orthotics, including helmets and cranial remodeling bands, for children with positional plagiocephaly or craniosynostosis. Coverage depends on clinical criteria, documented cranial asymmetry, prior treatment, surgical history where applicable, and the member’s contract benefits.

Policy Summary

PayerExcellus Health Plan Inc

PolicyCranial Orthotics

Policy CodePolicy 1.01.32

Change TypeClarification and definition updateno material coverage change

Effective DateFebruary 16, 2026

Next Review DateOctober 1, 2026

Key ActionDocument the child’s age, failed two-month conservative-treatment trial, and objective cranial asymmetry measurements supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

The October 16, 2025 off-cycle update revised formatting to clarify cranial asymmetry measurements for plagiocephaly with torticollis.

The October 16, 2025 update added a policy guideline definition of conservative treatment.

3–18 monthsCovered treatment age range

2 monthsRequired conservative-treatment trial

>12 mm or ≥6.25%Cranial asymmetry threshold

<76% or >90%

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentExcellus Health Plan IncPolicy 1.01.32

Cranial Orthotics

Customize your policy alerts

Sign up for excellus_health_plan_inc Policy 1.01.32 alerts

Get alerted when Policy 1.01.32 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerExcellus Health Plan Inc

PolicyCranial Orthotics

Policy CodePolicy 1.01.32

Change TypeClarification and definition updateno material coverage change

Effective DateFebruary 16, 2026

Next Review DateOctober 1, 2026

Key ActionDocument the child’s age, failed two-month conservative-treatment trial, and objective cranial asymmetry measurements supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

The October 16, 2025 off-cycle update revised formatting to clarify cranial asymmetry measurements for plagiocephaly with torticollis.

The October 16, 2025 update added a policy guideline definition of conservative treatment.

3–18 monthsCovered treatment age range

2 monthsRequired conservative-treatment trial

>12 mm or ≥6.25%Cranial asymmetry threshold

<76% or >90%

Brachycephaly threshold

2Contraindicated situations

Covered and Non-Covered Conditions

Non-synostotic positional plagiocephaly

Covered when ALL of the following are met:

Eligibility requirements

Age: The child is aged three (3) to 18 months.3-18 months
Failed conservative treatment: The child has failed a two-month trial of conservative treatment.2 months
Conservative treatment may include parent or caregiver education, a home exercise program, or physical therapy.
Documented cranial asymmetry
- Positional plagiocephaly measurement: Moderate-to-severe non-synostotic positional plagiocephaly, with or without torticollis, is documented by cranial vault asymmetry greater than 12 mm or cranial vault asymmetry index greater than or equal to 6.25%.CVA >12 mm or CVAI >=6.25%
- Brachycephaly measurement: Brachycephaly is documented by a cranial index less than 76% or greater than 90%.CI <76% or >90%

Craniosynostosis after surgery

Covered for the following indication:

Postoperative craniosynostosis: The cranial orthotic is for treatment of craniosynostosis (synostotic plagiocephaly) after surgical correction.After surgical correction

Persistent moderate-to-severe plagiocephaly after conservative treatment

Helmet therapy is recommended when the following clinical circumstances apply:

Persistent moderate-to-severe positional deformity

Conservative treatment
- A course of repositioning has been attempted.
- Parent or caregiver education has been attempted.
- A home exercise program has been attempted.
- Physical therapy has been attempted.

Advanced age with moderate-to-severe plagiocephaly

Helmet therapy may also be considered for:

Advanced age with significant deformity: The infant presents at an advanced age with moderate-to-severe plagiocephaly.

No single age threshold is specified. The recommendation is supported by CNS evidence-based guidance.

Second orthosis

A second orthosis may be considered when one or more of the following circumstances is present:

Second orthosis considerations

Despite every effort, the orthosis becomes ill-fitting or leaves little or no room for new growth.
Age and severity indicate another orthosis, and the parents are willing to continue.
The orthosis is prescribed for use as a continued postoperative adjunct or for preventative measures.

Hydrocephalus is a contraindication to cranial orthotic use; cranial orthotics are not considered medically appropriate for patients with this condition.

Craniosynostosis without prior surgical intervention is a contraindication to cranial orthotic use.

Cranial orthotics used primarily and customarily for convenience or safety are ineligible for coverage, including use for head protection during seizures or self-injurious behavior, even when there may be a remote medically related use.

Cranial orthosis use is contraindicated in patients with unshunted hydrocephalus.

Cranial orthosis use is contraindicated for craniosynostosis, except for an as-yet-undefined adjunctive postoperative use. FDA device summaries also identify craniosynostosis as a contraindication for cranial orthotic helmets and bands.

FDA-cleared cranial orthotic helmets and bands are indicated for moderate-to-severe nonsynostotic positional plagiocephaly, including plagiocephalic, brachycephalic, and scaphocephalic head shapes. These indications do not extend to synostotic conditions.

Treatment of non-synostotic positional plagiocephaly is not medically necessary in other situations, including mild deformity when the primary beneficial outcome is aesthetic.

Use of a cranial orthotic as the sole treatment of synostotic plagiocephaly is not medically necessary.

Replacement cranial orthotics are not medically necessary. A second orthotic may be reviewed case by case when documentation shows that the child's head has grown and the original orthotic no longer fits despite attempted adjustments, and that persistent cranial asymmetry continues to meet the applicable medical-necessity requirements.

Codes, Measurements, and Thresholds

CPT CodesCPT

No codes listed

HCPCS CodesHCPCS

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 orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

ICD10 CodesICD-10

Q67.0-Q67.4	Congenital musculoskeletal deformities of head and face (code range)
Q75.001-Q75.08	Craniosynostosis [surgically corrected] (code range)

Coding Thresholds

Required CVAGreater than 12 mm

Applies toModerate-to-severe non-synostotic positional plagiocephaly, with or without torticollis

MeasurementCranial vault asymmetry (CVA)

Coding Thresholds

Required CVAIGreater than or equal to 6.25%

Applies toModerate-to-severe non-synostotic positional plagiocephaly

Measurement

Documentation and Coverage Actions

Step Therapy

Complete Conservative Treatment Before Orthotic

Before requesting a cranial orthotic, document a minimum two-month trial of conservative treatment and the specific measures used. For children under six months, conservative treatment should include repositioning therapy and may include caregiver education, a home exercise program, or physical therapy.

Document the treatment dates and duration.
Describe repositioning, supervised tummy time, caregiver education, home exercises, and/or physical therapy.
Document the response and residual deformity after the trial.

Documentation Required

Document Persistent Deformity After Conservative Treatment

Document that moderate-to-severe deformational or positional plagiocephaly persists despite conservative treatment before initiating helmet therapy. The record should explain the lack of adequate response to repositioning, therapeutic exercises, and/or physical therapy.

Clinical Background

Plagiocephaly is an asymmetrically shaped head that may result from prenatal or perinatal compression. Nonsynostotic, or positional, plagiocephaly occurs while the cranial sutures remain open, whereas synostotic plagiocephaly results from premature closure of the cranial sutures. Cranial orthotics provide passive pressure to prominent or normally growing regions while allowing growth in flattened regions to improve cranial asymmetry or shape; the device must be adjusted as the child's head shape changes. Dynamic orthotic cranioplasty may be used as a postoperative adjunct after surgery for synostotic plagiocephaly.

Clinical Definitions

Definitions

DefinitionRatio of cranial width divided by cranial length, multiplied by 100

Normocephalic range76% through 90%

AbbreviationCI

Definitions

Measurement methodCompare measurements across the midline between designated points on the right and left sides of the skull

Measurement typeDistance-based cranial asymmetry measurement

Clinical useDetermines cranial vault asymmetry

Policy Summary

PayerExcellus Health Plan Inc

PolicyCranial Orthotics

Policy CodePolicy 1.01.32

Change TypeClarification and definition updateno material coverage change

Effective DateFebruary 16, 2026

Next Review DateOctober 1, 2026

Key ActionDocument the child’s age, failed two-month conservative-treatment trial, and objective cranial asymmetry measurements supporting medical necessity.

SourceLink

On This Page

Cranial vault asymmetry index (CVAI)

Coding Thresholds

Lower thresholdLess than 76%

Upper thresholdGreater than 90%

Applies toBrachycephaly

Coding Thresholds

Normocephalic range76% through 90%

MeasurementCranial index (CI)

CalculationWidth divided by length, multiplied by 100

Coding Thresholds

Normal CVALess than 3 mm

MeasurementDistance-based comparison of corresponding points on the right and left sides of the skull

InterpretationCranial vault asymmetry below 3 mm is within the normal range

Cranial Vault Asymmetry Severity

NormalLess than 3 mm

Mild/moderateLess than or equal to 12 mm

Moderate/severeGreater than 12 mm

Cranial Vault Asymmetry Index Severity

Within normal limitsLess than 3.5%

Minimal3.5% to 6.25%

Moderate6.25% to 8.75%

Moderately severe8.75% to 11.0%

SevereGreater than 11.0%

Conservative Treatment

Minimum durationTwo months

Applies toChildren under 6 months of age

Treatment may includeParent/caregiver education, a home exercise program, or physical therapy

Repositioning Therapy

Minimum durationAt least 6 to 8 weeks

Applies toInfants under 6 months of age

TherapyRepositioning therapy before cranial orthosis

State that the deformity is non-synostotic and persistent.
Describe the conservative measures attempted and the residual asymmetry.
Relate the findings to the medical-necessity criteria for helmet therapy.

Documentation Required

Document Initial Medical Necessity

The initial request should establish medical necessity by documenting the child’s age, the completed conservative-treatment trial, and objective cranial asymmetry measurements supporting moderate-to-severe deformity.

Document age between 3 and 18 months.
Document failure of a two-month conservative-treatment trial.
Document either cranial vault asymmetry greater than 12 mm or CVAI of at least 6.25% for plagiocephaly, or a cranial index below 76% or above 90% for brachycephaly.

Documentation Required

Record Cranial Assessment and Measurements

Include a cranial assessment with objective measurements supporting the diagnosis and severity of the deformity. Physical examination is generally recommended; imaging is rarely necessary.

Record cranial vault asymmetry (CVA) and cranial vault asymmetry index (CVAI).
Record skull-base asymmetry and other relevant skull or facial measurements.
Record the cephalic/cranial index when evaluating brachycephaly.
For the policy threshold, document CVA greater than 12 mm, CVAI at least 6.25%, or cranial index below 76% or above 90%, as applicable.

Documentation Required

Support a Second Orthotic Request

A request for a second orthotic is reviewed case by case. Demonstrate that the child’s head has grown and that the original orthotic no longer fits or remains appropriate after attempted adjustments; persistent asymmetry must still meet the applicable medical-necessity requirements.

Document growth of the head since the original orthotic was provided.
Document attempted adjustments and why the original orthotic can no longer be used.
Include current measurements showing persistent qualifying cranial asymmetry.

Billing Rule

Verify the Contract Benefit

Verify the member’s contract before submitting a cranial orthotic request. Orthotics are covered only when the subscriber contract includes an orthotic benefit or an external prosthetic device rider that covers orthotics.

Confirm the applicable product and subscriber contract.
Verify that the orthotic or external prosthetic device benefit is included.
Do not assume that medical necessity establishes coverage when the benefit is absent.

Denial Risk

Hydrocephalus Is a Contraindication

Cranial orthotics are contraindicated for hydrocephalus. Do not submit helmet or cranial remodeling band therapy without addressing this contraindication.

Screen for hydrocephalus before fitting or requesting the device.

Denial Risk

Uncorrected Craniosynostosis Is a Contraindication

Cranial orthotics are contraindicated for craniosynostosis without prior surgical intervention. Confirm that the deformity is non-synostotic or document the applicable surgical history before requesting coverage.

Do not treat uncorrected craniosynostosis with a cranial orthotic under this policy.
Document the diagnostic evaluation and any prior surgical intervention.

Denial Risk

Screen for Contraindicated Cranial Conditions

Screen for contraindicated cranial conditions before device selection and document the result. FDA device summaries and clinical guidance identify craniosynostosis and hydrocephalus, including unshunted hydrocephalus, as contraindications to cranial orthotic helmet or band use.

Address craniosynostosis in the diagnostic assessment.
Address hydrocephalus and specifically whether it is shunted.
Use the device only for the cleared indication of moderate-to-severe nonsynostotic positional deformity.

Denial Risk

Convenience or Safety Use Is Excluded

Devices used primarily and customarily for convenience or safety are not eligible for coverage, even if they may have a remote medically related use.

Do not request coverage primarily for head protection during seizures or self-injurious behavior.
Document the therapeutic purpose and qualifying cranial deformity.

Step Therapy

Complete the Two-Month Conservative Trial

For children under six months, conservative treatment should be trialed for at least two months before orthotic therapy. The record should identify the measures used and show that they were attempted before helmet treatment.

Use repositioning therapy, including reducing awake time spent on the back.
Include supervised tummy time and periodic changes to crib location when appropriate.
Add parent or caregiver education, a home exercise program, and/or physical therapy as clinically indicated.

Documentation Required

Document Conservative-Treatment History

Document the conservative-treatment history in sufficient detail to show what was attempted before helmet therapy. Appropriate measures include repositioning, caregiver education, supervised tummy time, home exercises, and physical therapy.

Record the type, frequency, and duration of each intervention.
Document caregiver instruction and adherence when available.
Describe the response and why additional orthotic treatment is needed.

Documentation Required

Confirm Persistent Qualifying Deformity

Helmet therapy is intended for infants with persistent moderate-to-severe plagiocephaly despite conservative therapy, including repositioning and/or physical therapy. Document the persistent deformity and objective severity before recommending the device.

Confirm the condition is deformational or positional and non-synostotic.
Document failure or insufficient response to conservative measures.
Include current CVA, CVAI, cranial index, or other qualifying measurements.

Billing Rule

Code Listing Does Not Guarantee Coverage

The presence of a code in the policy does not guarantee coverage. Codes may not be covered under all circumstances and remain subject to the member’s benefit and the policy’s medical-necessity requirements.

Do not rely on code listing alone to establish payment.
Submit supporting clinical documentation and verify benefit eligibility.

Billing Rule

Verify Product Benefit Coverage

Coverage is product-specific and contract dependent. If the member’s product does not cover the service, the medical policy criteria do not apply; if the product covers the service, the applicable medical-policy criteria apply to the benefit.

Verify coverage under the member’s commercial, Medicaid, or Medicare product.
Confirm the product includes the applicable orthotic or external prosthetic device benefit.
Apply the policy criteria only after confirming the service is a covered benefit.

Definitions

DeviceA device used for non-invasive treatment of non-synostotic or positional plagiocephaly

Growth effectInhibits growth in some areas of an infant’s skull and enables growth in others

GoalImprove cranial asymmetry and/or shape

Definitions

EducationParent/caregiver education

Home treatmentA home exercise program

TherapyPhysical therapy

Definitions

DeviceA device used for non-invasive treatment of non-synostotic or positional plagiocephaly

Remodeling functionInhibits growth in some skull areas and permits growth in others

PurposeImprove cranial asymmetry or shape

Definitions

Measurement typeDistance-based measurement of cranial asymmetry

ComparisonCorresponding points on the right and left sides of the skull

Severity referenceNormal is less than 3 mm; mild/moderate is less than or equal to 12 mm; moderate/severe is greater than 12 mm

Definitions

Measurement typePercentage measurement

CalculationAbsolute difference between corresponding 30-degree cranial measurements divided by the greater measurement

Reference pointMeasurements are taken 30 degrees from the center of the nose or the outer edge of the eyebrow

Definitions

ConditionAn asymmetrically shaped head

CausePremature closure of the cranial sutures

TermSynostotic plagiocephaly

Definitions

ConditionPositional or deformational plagiocephaly

SuturesThe cranial sutures remain open

Also calledPlagiocephaly without synostosis

Definitions

Primary morphologyShortened skull with increased width and height, or an elongated and narrow skull

Associated conditionBrachycephaly results from bilateral coronal synostosis

Positional formMild, transient brachycephaly can occur as a positional deformity without sutural synostosis

Definitions

DeviceA dynamic orthotic cranial remodeling device

Proposed usePostoperative adjunct

IndicationPatients undergoing surgery for synostotic plagiocephaly