Currentsierra health and lifePolicy 2026T0031GG

Plagiocephaly and Craniosynostosis Treatment

Defines coverage stance for cranial orthotic devices and related treatments for infants with craniosynostosis or nonsynostotic positional plagiocephaly under UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

Payersierra health and life

PolicyPlagiocephaly and Craniosynostosis Treatment

Policy CodePolicy 2026T0031GG

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review Date

Key ActionFollow InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling for prior authorization and medical necessity determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Class IIFDA device classification

3–18 moFDA-indicated infant age range

InterQualClinical criteria source

D5924,L0112,L0113,S1040Example listed codes

Coverage Criteria

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Cranial orthoses - post-surgical: Cranial orthotic devices are proven and medically necessary for treating infants following craniosynostosis surgery

Refer to Surgical policy for CPT 21175 for the surgical repair; see InterQual criteria for details

Cranial orthoses - nonsynostotic plagiocephaly: Cranial orthotic devices are proven and medically necessary for nonsynostotic (deformational or positional) plagiocephaly

Medical necessity clinical coverage criteria per InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling

The listing of procedure and diagnosis codes in this policy is provided for reference only and does not imply that the service described by a code is a covered or non‑covered health service. Benefit coverage is determined by the member’s specific benefit plan and applicable law; inclusion of a code does not guarantee reimbursement or claim payment.

Coding

Listed HCPCS codesHCPCS

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)

FDA indicated age range

FDA device classificationClass II

FDA special controls requiredPrescription use, biocompatibility testing, and labeling (contraindications, warnings, precautions, adverse events, and instructions)

FDA-indicated infant age range3 to 18 months

Intended clinical use per FDAApply pressure to prominent regions of an infant's cranium to improve cranial symmetry and/or shape

Provider Actions & Documentation

Note

InterQual-based medical necessity

Coverage follows InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling. For medical necessity clinical coverage criteria, use the InterQual criteria linked in the policy.

InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling

Prior Authorization

Provider note — action required

Prior to submitting a request, confirm whether prior authorization is required by the member's specific benefit plan. Provide complete clinical documentation that supports meeting InterQual criteria. Incomplete or missing documentation may result in delayed review or denial.

Confirm member-specific prior authorization requirements
Submit complete medical records demonstrating InterQual criteria are met

Documentation Required

Medical records may be required

Medical records and documentation may be requested to determine whether the member meets clinical criteria. Documentation does not guarantee coverage; benefits are determined by the member's plan and applicable laws.

Refer to Medical Records Documentation Used for Reviews guidance

Denial Risk

Coverage and documentation risk

Coverage is determined by the member-specific benefit plan and applicable laws. Even when clinical criteria are met, benefit limitations or exclusions in the member's plan may affect coverage. Verify member benefits prior to ordering or billing.

Benefit coverage subject to member-specific plan documents and applicable law
Listing of codes in policy is for reference only and does not guarantee payment

Definitions

Devices intended to apply pressure to prominent regions of an infant's cranium to improve cranial symmetry and/or shape — cranial orthoses (cranial remolding helmets)

Definition (term)Cranial orthoses (cranial remolding helmets)

Primary purposeApply pressure to prominent regions of an infant's cranium to improve cranial symmetry and/or shape

Clinical indications in policyTreatment after craniosynostosis surgery and for moderate to severe nonsynostotic (deformational/positional) plagiocephaly

FDA classificationClass II device (subject to special controls)

Background

Craniosynostosis is the premature fusion of one or more cranial sutures and may require surgical repair. Nonsynostotic (deformational or positional) plagiocephaly is a head‑shape deformity without suture fusion. Cranial orthoses (cranial remolding helmets) are devices intended to apply pressure to prominent regions of an infant’s cranium to improve skull symmetry and shape, and they are used postoperatively for craniosynostosis or to improve symmetry in moderate to severe positional plagiocephaly during infancy.