Cranial Orthotics (Cranial bands and helmets)
Customize your policy alerts
Sign up for all moda_health_plan_inc policy alerts
Know when moda_health_plan_inc releases new policies or updates existing guidance.
Monitor payer policy activity
Defines coverage criteria, required documentation, and applicable billing codes for cranial orthotic devices (bands and helmets) for infants, and who is eligible under Moda Health Plan Inc.
No material clinical or coverage changes in this revision.
Coverage Criteria for Cranial Orthotics
Second cranial remodeling device
Covered when ALL of the following are met:
See chunk 3
Moda Health considers the use of cranial orthotics (bands or helmets) to be experimental and investigational for indications not listed in the policy criteria. This expressly includes, but is not limited to, use in infants with synostotic plagiocephaly (craniosynostosis) who have not had surgical correction.
Requests for cranial orthotics for indications outside those specified in this policy (see exclusions) are not medically necessary and will not be covered.
Applicable Billing and Diagnosis Codes
| A8000 | Helmet, protective, soft, prefabricated, includes all components and accessories |
| A8001 | Helmet, protective, hard, prefabricated, includes all components and accessories |
| A8002 | Helmet, protective, soft, custom fabricated, includes all components and accessories |
| A8003 | Helmet, protective, hard, custom fabricated, includes all components and accessories |
| A8004 | Soft interface for helmet, replacement only |
| L0112 | Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated |
| S1040 | Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) |
| M43.6 | Torticollis |
| M95.2 | Other acquired deformity of head |
| M95.3 | Acquired deformity of neck |
| P13.0 | Fracture of skull due to birth injury |
| Q18.8 | Other specified congenital malformations of face and neck |
| Q67.0 | Congenital facial asymmetry |
| Q67.1 | Congenital compression facies |
| Q67.2 | Dolichocephaly |
| Q67.3 | Plagiocephaly |
| Q67.4 | Other congenital deformities of skull, face and jaw |
Provider Actions, Prior Authorization, and Documentation
Conservative therapy trial required (infants <6 months)
For infants under 6 months, coverage requires failure of a 2-month trial of conservative therapy (repositioning and/or physical therapy) before a cranial orthotic will be covered; for infants 6 months or older a repositioning trial may not be appropriate.
- Trial duration: 2 months for infants <6 months
- Therapies: repositioning and/or physical therapy
Required documentation for prior authorization
The prior authorization request must include chart notes documenting the conservative therapy attempted and a treatment plan that includes anthropometric (skull measurement) data recorded by a provider experienced in these measurements.
- Chart notes from treating physician documenting conservative therapy tried
- Treatment plan including anthropometric data documented by a provider experienced in these measurements (e.g., the orthotist fitting the band or helmet)
Triggers for denial
Requests may be denied if initiation is in patients older than 12 months, if required conservative therapy trial (when applicable) is not documented, if anthropometric measurements do not meet the asymmetry or cephalic index thresholds, or if the infant has un-shunted or uncontrolled hydrocephalus.
- Patient age at initiation must be ≤ 12 months
- Failure of 2-month conservative therapy must be documented for infants <6 months
- Asymmetry must be >6 mm in one or more skull measurements or cephalic index ≥2 SD from mean
- Not approved for infants with un-shunted or uncontrolled hydrocephalus
Definitions
Background
Positional plagiocephaly is skull asymmetry frequently resulting from external pressure and positioning factors such as in‑utero posture, supine sleeping, prematurity, or tightness of the sternocleidomastoid muscle. Conservative measures including repositioning and increased prone time often correct mild cases; cranial orthotic helmets or bands are used when conservative care fails or as part of post‑operative management. Non‑positional causes include craniosynostosis and conditions like hydrocephalus, which may require surgical management and for which orthotics alone are not appropriate.
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.