CurrentUnitedHealthcarePolicy CS095NE.U

Plagiocephaly Craniosynostosis Treatment Ne Cs

State-specific UnitedHealthcare medical policy for Nebraska governing coverage of cranial orthotic devices for infants with craniosynostosis post-surgery and nonsynostotic (deformational/positional) plagiocephaly, with references to InterQual® criteria and related policies for surgery and device repair/replacement.

Policy Summary

PayerUnitedHealthcare

PolicyPlagiocephaly Craniosynostosis Treatment Ne Cs

Policy CodePolicy CS095NE.U

Change TypeRoutine review; no content changes

Effective DateFebruary 1, 2026

Next Review Date

Key ActionObtain and document that InterQual® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling criteria are satisfied and ensure medical record documentation supports medical necessity.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

NebraskaGeographic Scope

InterQualClinical Criteria

IIFDA Class

Coverage Summary

Overview: This Nebraska-specific UnitedHealthcare medical policy (Policy Number CS095NE.U) is covered with criteria for cranial orthotic devices when InterQual® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling clinical criteria are met, and additionally for postoperative craniosynostosis. Effective date: 2026-02-01. Last review: 2026-02-01.

Medical Necessity / Coverage Rationale

Coverage Rationale / Medical Necessity Criteria

Cranial orthotic devices are covered when criteria in InterQual® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling are met; additionally covered for postoperative craniosynostosis.

ANY of the following

Postoperative craniosynostosis
- Infant following craniosynostosis surgery
  Cranial orthotic devices are proven and medically necessary post-surgery
- Clinical coverage criteria per InterQual® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling are met
  Refer to InterQual® for specific measurable criteria
Nonsynostotic (deformational/positional) plagiocephaly
- Diagnosis of nonsynostotic (nonfusion) deformational or positional plagiocephaly
  Includes plagiocephalic, brachycephalic, and scaphocephalic head shapes
- Clinical coverage criteria per InterQual® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling are met
  Refer to InterQual® for age, severity, and prior conservative therapy requirements

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Provider Actions & Requirements

Prior Authorization

Prior authorization / clinical criteria reference

Coverage requires meeting InterQual® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling criteria. Providers should obtain and document that the InterQual® criteria are satisfied when requesting coverage or prior authorization.

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation should be legible, maintained in the patient's medical record, and must be made available upon request.

Billing Rule

Code guidance is reference only

The following codes are provided for reference only and do not guarantee coverage or reimbursement. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

D5924
L0112
L0113
S1040

Background

Background: Cranial orthoses are FDA Class II devices intended to apply pressure to prominent regions of an infant’s cranium to improve cranial symmetry and shape in infants approximately 3 to 18 months of age with moderate to severe nonsynostotic positional plagiocephaly, including plagiocephalic, brachycephalic, and scaphocephalic head shapes.

Policy application and references: The policy defers to InterQual® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling for specific medical necessity determinations. Separate UnitedHealthcare policies apply for surgical repair of craniosynostosis (see Cosmetic and Reconstructive Procedures policy for CPT 21175) and for repair or replacement of cranial orthoses (see Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements policy).

Definitions: Nonsynostotic positional plagiocephaly — deformational (nonfusion) cranial asymmetry, including plagiocephalic, brachycephalic, and scaphocephalic head shapes.

Regulatory / Evidence Notes

FDA product codeMVA (Class II device information referenced, accessed 2024-08-29)

FDA classificationClass II device — requires prescription use, biocompatibility testing, and labeling with contraindications/warnings/precautions

Intended age rangeInfants approximately 3 to 18 months of age

Indications per FDA wordingFor moderate to severe nonsynostotic positional plagiocephaly to improve cranial symmetry/shape

Head shape examplesIncludes plagiocephalic, brachycephalic, and scaphocephalic-shaped heads

OpenPayer

Plagiocephaly Craniosynostosis Treatment Ne Cs

Coverage Summary

Medical Necessity / Coverage Rationale

Coding

Provider Actions & Requirements

Background

Revision History

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)