CurrentUnitedHealthcarePolicy CS095NJ.M

Plagiocephaly Craniosynostosis Treatment Nj Cs

State-specific UnitedHealthcare medical policy (New Jersey) addressing coverage of cranial orthotic devices for infants after craniosynostosis surgery or for nonsynostotic deformational/positional plagiocephaly, with references to InterQual criteria and related policies for surgical repair and orthosis repairs/replacements.

Policy Summary

PayerUnitedHealthcare

PolicyPlagiocephaly Craniosynostosis Treatment (for New Jersey Only)

Policy CodePolicy CS095NJ.M

Change TypeDocumentation requirements addedHCPCS note removed

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record contains legible documentation that fully supports medical necessity, including relevant history, physical exam, and diagnostic results, and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying medical records documentation requirements for reviews and coverage determinations.

Removed notation that HCPCS code S1040 is not on the State of New Jersey Medicaid Fee Schedule.

2Primary covered indications specified

4Referenced billing/product codes

Coverage Summary

This is a state-specific UnitedHealthcare (New Jersey) medical policy (Policy Number CS095NJ.M) that covers use of cranial orthotic devices for infants following craniosynostosis surgery and for nonsynostotic deformational/positional plagiocephaly. The policy is covered_with_criteria. Effective date: February 1, 2026; Last review: February 1, 2026.

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Medically Necessary Coverage

Cranial orthotic devices are proven and medically necessary when used for the following indications:

ANY of the following

Infants following craniosynostosis surgery
Infants with nonsynostotic (nonfusion) deformational or positional plagiocephaly

Clinical Criteria Source

For medical necessity clinical coverage criteria, refer to the InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling
For surgical treatment to repair craniosynostosis (CPT code 21175), refer to Medical Policy titled Cosmetic and Reconstructive Procedures (for New Jersey Only)
For repair or replacement of cranial orthoses, refer to Medical Policy titled Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for New Jersey Only)

Benefit coverage is determined by federal, state, or contractual requirements; medical records documentation may be required and must fully support medical necessity (relevant history, physical exam, and results of pertinent diagnostic tests/procedures) and be made available upon request.

The third-party clinical criteria referenced for medical necessity determinations is InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling. Prior authorization reviewers will use these InterQual criteria to assess coverage for cranial orthoses.

Referenced Billing and Product Codes

Referenced HCPCS / D codesmixed

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).

Referenced CPTCPT

21175

Repair of craniosynostosis (referenced policy for surgical treatment).

Provider Actions & Requirements

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 record, and made available upon request.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Legible documentation maintained in the patient's medical record
Records must be made available upon request

Prior Authorization

Use InterQual criteria for medical necessity determination

Medical necessity clinical coverage criteria are determined by referring to InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling; prior authorization reviewers will use these criteria to assess coverage.

Prior authorization reviewers will reference InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling when assessing medical necessity

Background

Cranial orthoses are classified by the FDA as Class II devices intended to improve cranial symmetry in infants aged 3 to 18 months with moderate to severe nonsynostotic positional plagiocephaly. These devices are subject to special controls, including prescription use, biocompatibility testing, and required labeling. This policy applies only to the state of New Jersey.

InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling is the third-party clinical criteria referenced for determining medical necessity for cranial orthoses.

Revision History

2026-02-01material_change_addedLatest

Added language clarifying medical records documentation requirements for reviews and coverage determinations: specifies benefit coverage is determined by federal, state, or contractual requirements and applicable laws; medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; patient medical record must contain documentation fully supporting medical necessity (including relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures); documentation should be legible, maintained in the record, and made available upon request.

2026-02-01non_material_change_removed

Removed notation that HCPCS code S1040 is not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.