CurrentTexas Children's Health PlanPolicy 6179

Cranial Molding Orthosis Guidelines

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This guideline governs prior authorization and medical-necessity review for cranial molding orthosis devices requested for Texas Children's Health Plan members. It defines covered indications, non-covered indications, documentation requirements, and lifetime device limitations.

Policy Summary

PayerTexas Children's Health Plan

PolicyCranial Molding Orthosis Guidelines

Policy CodePolicy 6179

Change TypeNo material change

Effective DateFeb 22, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests for all cranial molding orthosis devices to the Utilization Management Department by fax, mail, or electronically.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3–18 monthsEligible member age range

Once per lifetimeBenefit limit

3Additional-device conditions

AllDevices requiring authorization

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CurrentTexas Children's Health PlanPolicy 6179

Cranial Molding Orthosis Guidelines

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Sign up for texaschildrenshealthplan Policy 6179 alerts

Get alerted when Policy 6179 changes without checking for updates manually.

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Policy Summary

PayerTexas Children's Health Plan

PolicyCranial Molding Orthosis Guidelines

Policy CodePolicy 6179

Change TypeNo material change

Effective DateFeb 22, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests for all cranial molding orthosis devices to the Utilization Management Department by fax, mail, or electronically.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3–18 monthsEligible member age range

Once per lifetimeBenefit limit

3Additional-device conditions

AllDevices requiring authorization

Initial therapy

Medically necessary when ALL of the following are met:

Initial medical-necessity criteria

Age: The member is 3 through 18 months of age.3 through 18 months
Diagnosis and treatment plan: The orthosis is part of a treatment plan for a documented diagnosis of synostotic plagiocephaly.Documented synostotic plagiocephaly

Additional device or replacement

Additional devices beyond the once-per-lifetime benefit may be considered when ALL of the following are documented:

Additional-device criteria

Initial indication: The initial device was obtained to treat synostotic plagiocephaly.Synostotic plagiocephaly
Treatment response: Treatment with the device has been effective.Effective treatment
Growth-related need: The new device is needed due to growth.Need due to growth

Not medically necessary indications

Not medically necessary as a treatment for either of the following:

Non-covered indications

Positional condition: Non-synostotic or positional plagiocephaly.
Considered cosmetic.
Brachycephaly.
Efficacy is not clearly documented.

Non-synostotic or positional plagiocephaly is excluded as a treatment indication because it is considered cosmetic.

Brachycephaly is excluded as a treatment indication because the efficacy of cranial molding orthosis for this condition is not clearly documented.

Cranial molding orthosis is considered not medically necessary for non-synostotic or positional plagiocephaly.

Cranial molding orthosis is considered not medically necessary for brachycephaly.

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for all cranial molding orthosis devices. Requests must be submitted to the Utilization Management Department by fax, mail, or electronically during normal business hours.

Applies to cranial molding orthosis requests, including S1040 devices.

Note

Utilization Management Review

Utilization Management reviews the submitted information to determine whether the documentation supports the cranial molding orthosis request as an eligible service.

Preauthorization is based on medical necessity and does not guarantee benefits or eligibility.
All services remain subject to benefit limitations and exclusions.

Unsupported block type: billing_rule

Documentation Required

Medical-Necessity Documentation

The requesting physician must provide documentation supporting the medical necessity of the cranial molding orthosis.

Documentation should support the member's diagnosis, age, and treatment plan when applicable.

Documentation Required

Documentation for Replacement or Additional Device

For a device beyond the once-per-lifetime benefit, submit documentation showing that the initial device was obtained to treat synostotic plagiocephaly, treatment has been effective, and the new device is needed due to growth.

All listed documentation elements are required for consideration of the additional device.

Denial Risk

Failure to Meet Coverage Criteria

Requests that do not meet the established coverage criteria are referred to a TCHP Medical Director or Physician Reviewer. The Denial Policy will be followed for requests that remain unsupported or do not meet criteria.

Providers should ensure the submitted record addresses all applicable medical-necessity and benefit-limit requirements.

Prior Authorization

Additional Device Beyond Lifetime Limit

An additional cranial molding orthosis beyond the once-per-lifetime limit requires prior authorization and documentation supporting all required conditions for consideration.

The initial device treated synostotic plagiocephaly.
Treatment with the initial device has been effective.
The additional device is needed because of member growth.

Policy Definitions

Cranial Molding Orthosis

Device terminologyExternal braces including helmet orthosis, cranial orthosis, cranial orthotic device, and orthotic headbands.

PurposeKnown to be effective for correcting the asymmetrical shape of the head.

Synostotic plagiocephaly or craniosynostosis

DefinitionAn asymmetrically shaped head due to premature closure of one or more cranial sutures, causing restricted skull growth and worsening head deformity.

Clinical descriptionPlagiocephaly accompanied by craniosynostosis may require surgery to reopen the closed sutures.

Non-synostotic plagiocephaly

DefinitionA condition in which an infant's head becomes deformed due to external forces applied over time.

Also known asPositional plagiocephaly.

Treatment descriptionCan be treated without surgical correction.

Brachycephaly

DefinitionA head shape that is symmetric and disproportionately wide.

Possible causeAbnormal growth of the skull bone plates.

Positional descriptionPositional brachycephaly is due to an infant being placed in the same supine position for prolonged periods of time.

Cranial Molding Orthosis Guidelines

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Cranial Molding Orthosis Guidelines

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Medical Necessity and Coverage Criteria

Applicable Coding

Authorization and Documentation Requirements

Cranial Molding Orthoses

Policy Definitions