CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

Cranial Remolding Orthosis

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This policy governs coverage and service authorization for pediatric cranial remolding orthoses, including cranial bands or helmets billed under HCPCS S1040, for North Dakota Medicaid fee-for-service providers.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyCranial Remolding Orthosis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewDec 17, 2025

Next Review DateN/A

Key ActionSubmit service authorization requests through Kepro's Atrezzo Provider Portal for InterQual review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

S1040Service code

YesAuthorization required

90 daysExam-to-authorization interval

3–18 monthsHistorical age range

6 / 8 / 4 mmHistorical asymmetry thresholds

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CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

Cranial Remolding Orthosis

Customize your policy alerts

Sign up for all North Dakota Department of Health & Human Services policy alerts

Know when North Dakota Department of Health & Human Services releases new policies or updates existing guidance.

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Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyCranial Remolding Orthosis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewDec 17, 2025

Next Review DateN/A

Key ActionSubmit service authorization requests through Kepro's Atrezzo Provider Portal for InterQual review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

S1040Service code

YesAuthorization required

90 daysExam-to-authorization interval

3–18 monthsHistorical age range

6 / 8 / 4 mmHistorical asymmetry thresholds

2–4 monthsReplacement-device interval

Coverage Criteria

Historical positional deformity criteria

The following criteria are historical criteria reproduced in the revision history. Current authorization requests are submitted through Kepro’s Atrezzo Provider Portal and reviewed using InterQual coverage criteria.

Conservative therapy
- Coverage was historically considered medically necessary for moderate to severe positional head deformity refractory to therapeutic physical adjustments and position changes, when band or helmet therapy was initiated at 3 to 18 months of age.Age 3 to 18 months
- Marked asymmetry had not substantially improved after at least 2 months of cranial repositioning therapy, with or without physical therapy.At least 2 months
  Because of the mobility of children older than 6 months, repositioning therapy was described as ineffective and a trial was not indicated.
Objective deformity measurement
- Skull base asymmetry measured at least 6 mm from the right to left side.At least 6 mm right/left discrepancy
- Cranial vault asymmetry measured at least 8 mm from the right to left side.At least 8 mm right/left discrepancy
- Orbitotragial distances showed at least 4 mm right/left asymmetry.At least 4 mm right/left asymmetry
- For brachycephaly, the cephalic index was 2 standard deviations below or 2 standard deviations above the mean in a child older than 3 months and younger than 18 months.2 standard deviations below or above the mean; after 3 months and before 18 months of age

Post-surgical and replacement-device criteria

The following post-surgical and replacement-device criteria are historical criteria reproduced in the revision history. Current authorization is subject to InterQual review.

Applicable post-surgical or replacement-device pathway

Post-surgical synostotic plagiocephaly: A cranial remodeling band or helmet may be medically necessary for an infant with synostotic plagiocephaly who has continued moderate to severe asymmetry following surgical correction.Residual moderate to severe asymmetry after surgical correction
Conservative therapy is not required when the device is used following surgery for synostotic plagiocephaly.
Second band or helmet
- The child meets the applicable medical-necessity criteria for cranial remodeling orthosis.
- Asymmetry has not resolved after 2 to 4 months.

Use of a cranial remodeling band or helmet without surgery to correct asymmetry in infants with synostotic plagiocephaly is considered cosmetic and is not covered as medically necessary.

Use of a cranial remodeling band or helmet for a person who does not meet the applicable coverage criteria is considered cosmetic.

A cranial remodeling band or helmet is not medically necessary when the member does not meet the applicable medical-necessity criteria.

Coding and Clinical Thresholds

Cranial Remolding OrthosisHCPCSCovered

S1040

Cranial remolding orthosis

Skull Base Asymmetry

ThresholdAt least 6 mm right/left discrepancy

MeasurementMeasured subnasally to the tip of the tragus

Clinical contextOne documented objective asymmetry threshold in the historical criteria

Cranial Vault Asymmetry

ThresholdAt least 8 mm right/left discrepancy

MeasurementMeasured from the frontozygomaticus point to the contralateral euryon

Clinical context

Authorization and Documentation

Prior Authorization

Prior Authorization Required

Service authorization is required for pediatric cranial remolding orthosis (HCPCS S1040). Submit all requests through Kepro’s Atrezzo Provider Portal for review under InterQual coverage criteria.

Required route: Kepro’s Atrezzo Provider Portal.
Review basis: InterQual coverage criteria.

Documentation Required

Required Clinical Documentation

Include the required clinical documentation with the authorization request, including the prescription, timely practitioner examination, and records supporting medical necessity.

Prescription from a prescribing practitioner.
Practitioner examination performed within 90 days of the service authorization start date.

Clinical Background

A cranial remolding orthosis is a band or helmet used in infants and children to guide cranial growth and correct cranial asymmetry or deformity. The policy addresses positional head deformity, plagiocephaly, brachycephaly, and residual asymmetry after surgical correction of synostotic plagiocephaly.

Defined Clinical Terms

Skull Base Asymmetry

DefinitionA right/left discrepancy of the skull base

Starting landmarkSubnasal measurement point

Ending landmarkTip of the tragus, the cartilaginous projection of the auricle at the front of the ear

Cranial Vault Asymmetry

DefinitionA right/left discrepancy of the cranial vault

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

Opposite landmark

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyCranial Remolding Orthosis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewDec 17, 2025

Next Review DateN/A

Key ActionSubmit service authorization requests through Kepro's Atrezzo Provider Portal for InterQual review.

SourceLink

On This Page

Persistent asymmetry after 2 to 4 months

The medical record supports significant head growth.

The current band or helmet cannot provide any additional growth adjustments.

One documented objective asymmetry threshold in the historical criteria

Orbitotragial Asymmetry

ThresholdAt least 4 mm right/left asymmetry

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

Clinical contextOne documented objective asymmetry threshold in the historical criteria

Brachycephaly Cephalic Index

ThresholdCephalic index 2 standard deviations below the mean or 2 standard deviations above the mean

InterpretationBelow the mean indicates a head narrow for its length; above the mean indicates a head wide for its length

Age applicabilityAfter 3 months of age and before 18 months of age

Historical Initiation Age

Historical initiation age3 to 18 months of age

Brachycephaly age rangeAfter 3 months of age and before 18 months of age

Historical treatment contextBand or helmet therapy for moderate to severe positional head deformities

Medical documentation supporting the need for the cranial remolding orthosis.

Documentation Required

Document Cranial Measurements

Document the applicable cranial asymmetry measurements and, for brachycephaly, the cephalic index supporting coverage. Measurements are generally obtained by the orthotist fitting the band or helmet.

Skull base asymmetry: At least 6 mm right/left discrepancy, measured sub nasally 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.
Orbitotragial distance asymmetry: At least 4 mm right/left asymmetry, measured from the lateral aspect of the orbit to the tip of the ipsilateral tragus.
Brachycephaly: Cephalic index 2 standard deviations below or above the mean; calculate as head width (eu-eu) × 100 divided by head length (g-op). Coverage applies to a child after 3 months of age and before 18 months of age.

Documentation Required

Additional Device Documentation

For a second cranial remodeling band or helmet, document that the child continues to meet the applicable criteria and that the current device is no longer adequate.

Asymmetry has not resolved after 2 to 4 months.
The medical record supports significant head growth.
The current band or helmet cannot provide any additional growth adjustments.

Denial Risk

Cosmetic Use or Criteria Failure

A cranial remodeling band or helmet is considered cosmetic when used for synostotic plagiocephaly without surgery or for individuals who do not meet the applicable coverage criteria.

Use following surgery for synostotic plagiocephaly may be medically necessary to correct continued asymmetry; conservative therapy is not required in that circumstance.
Use without surgery to correct asymmetry in infants with synostotic plagiocephaly is considered cosmetic.
Use for persons who do not meet the stated criteria is considered cosmetic.

Denial Risk

Insufficient Support for Replacement Device

A request for a second or replacement device is not sufficiently supported when the record does not establish persistent asymmetry, significant head growth, and the inability of the current device to accommodate further growth.

Persistent asymmetry after 2 to 4 months must be documented.
Significant head growth must be supported in the medical record.
The current band or helmet must be unable to provide additional growth adjustments.

Unsupported block type: denial_risk被ت{

Contralateral euryon, the most lateral point on the head in the parietal region

Cephalic Index

FormulaCephalic index = head width (eu–eu) × 100 ÷ head length (g–op)

Head widthFrom euryon on one side of the head to euryon on the other side; measures the greatest transverse diameter

Head lengthFrom glabella to opisthocranion; measures maximal head depth or length

Synostotic Plagiocephaly

DefinitionCranial asymmetry associated with craniosynostosis

Post-surgical residual deformityA cranial remodeling band or helmet may be medically necessary for continued asymmetry following surgery

Use without surgeryUse of a cranial remodeling band or helmet without surgery to correct asymmetry is considered cosmetic