CurrentUnitedHealthcarePolicy CS095OH.C

Plagiocephaly and Craniosynostosis Treatment (for Ohio Only) – Community Plan Medical Policyopen_in_new

Defines UnitedHealthcare Ohio-specific medical policy referencing Ohio Administrative Code for coverage, medical necessity, and documentation requirements for cranial remolding devices (cranial orthoses) and directs surgical craniosynostosis repair to a separate policy.

Policy Summary

PayerUnitedHealthcare

PolicyPlagiocephaly and Craniosynostosis Treatment (for Ohio Only) – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS095OH.C

Change TypeDocumentation language addedprior version archived

Effective DateMarch 1, 2026

Next Review Date

Key ActionInclude relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures in the patient's medical record; these must be legible and available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews language added clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required and does not guarantee coverage.

Archived previous policy version CS095OH.B.

4Referenced HCPCS/CPT codes

1State-specific policy (Ohio)

1FDA device class noted

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This Ohio-specific policy (Plagiocephaly and Craniosynostosis Treatment, Policy Number CS095OH.C) defines coverage and medical necessity determinations for cranial remolding devices and related services and is effective March 1, 2026 (last reviewed March 1, 2026). The policy applies only in Ohio and states that requests for services that are unproven or subject to coverage/quantity limits will be evaluated using Ohio Administrative Code requirements.

Key Policy Attributes

Policy NumberCS095OH.C

PayerUnitedHealthcare

Policy TitlePlagiocephaly and Craniosynostosis Treatment (for Ohio Only)

State ScopeOhio

Coverage stancemixed

Effective date2026-03-01

Last review2026-03-01

Medical-Necessity Criteria and Application

Application

Policy applies only to Ohio and defers to Ohio Administrative Code for medical necessity evaluations:

ALL of the following

Service requests in Ohio governed by this Medical Policy; services stated as unproven or with coverage or quantity limits will be evaluated using Ohio Administrative Code 5160-101.

Coverage Rationale for Cranial Remolding Devices

Coverage and medical necessity determined by Ohio Administrative Code references:

Refer to Ohio Administrative Code, Rule 5160-10-35 for medical necessity clinical coverage criteria for cranial remolding devices.

For general DME coverage/payment and exclusions, refer to Ohio Administrative Code, Rule 5160-10-01.

Cranial orthoses are FDA Class II devices intended for infants 3 to 18 months with moderate to severe nonsynostotic positional plagiocephaly (including plagiocephalic-, brachycephalic-, and scaphocephalic-shaped heads) to improve cranial symmetry and/or shape.

Surgical treatment to repair craniosynostosis (CPT 21175) is addressed under the separate policy 'Cosmetic and Reconstructive Procedures (for Ohio Only)'.

Medical Records Documentation Used for Reviews

Coverage requires supporting medical record documentation:

Benefit coverage determined by federal, state, or contractual requirements and applicable laws; documentation may be required to assess whether member meets clinical criteria but does not guarantee coverage.

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.

Documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation must be legible, maintained in the patient's medical record, and made available upon request.

Provider Actions and Requirements

Documentation Required

Support medical necessity with records

Include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures in the patient's medical record to support medical necessity. Documentation must be legible, maintained in the patient's medical record, and made available upon request. 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.

relevant medical history, physical exam, and results of pertinent diagnostic tests
records must be legible and available upon request

Prior Authorization

Evaluation under Ohio Administrative Code

Requests for services stated as unproven or services for which there is a coverage or quantity limit will be evaluated for medical necessity using Ohio Administrative Code, including Rule 5160-10-35 and Rule 5160-10-01.

Billing Rule

Code usage guidance

The following HCPCS/CPT codes are provided for reference only. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service and does not guarantee reimbursement or claim payment. Verify benefit, state law, and contract requirements before billing.

D5924
L0112
L0113
S1040
21175
Inclusion of a code does not guarantee coverage — verify benefit/state/contract prior to billing

Coding

HCPCS / DME codes referencedHCPCS

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 orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s).

CPT referenced for craniosynostosis surgeryCPT

21175

Surgical treatment to repair craniosynostosis (refer to separate policy).

Background

This policy is specific to the state of Ohio and ties coverage and medical necessity determinations to the Ohio Administrative Code for DMEPOS and cranial remolding devices (see Rules 5160-10-01 and 5160-10-35). It references applicable HCPCS/CPT codes for cranial prostheses and orthoses (e.g., D5924, L0112, L0113, S1040, and CPT 21175 for craniosynostosis surgery) for billing/reference purposes. Cranial orthoses are FDA Class II devices intended to apply pressure to prominent regions of an infant's cranium to improve cranial symmetry/shape in infants aged 3 to 18 months with moderate to severe nonsynostotic positional plagiocephaly (including plagiocephalic-, brachycephalic-, and scaphocephalic-shaped heads).

Definitions

TermCranial orthoses / cranial remolding devices

DefinitionMedical devices intended to apply pressure to prominent regions of an infant's cranium to improve cranial symmetry/shape in infants from 3 to 18 months with moderate to severe nonsynostotic positional plagiocephaly.

Revision History

2026-03-01material_changeLatest

2026-03-01material_change_detailLatest

Added specifics that documentation includes relevant medical history, physical exam, and pertinent diagnostic tests and that records must be legible and available upon request.

archivedarchived_policy

Archived previous policy version CS095OH.B.

Policy Summary

PayerUnitedHealthcare

PolicyPlagiocephaly and Craniosynostosis Treatment (for Ohio Only) – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS095OH.C

Change TypeDocumentation language addedprior version archived

Effective DateMarch 1, 2026

Next Review Date

Key ActionInclude relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures in the patient's medical record; these must be legible and available upon request.

SourceLink

On This Page

OpenPayer

Plagiocephaly and Craniosynostosis Treatment (for Ohio Only) – Community Plan Medical Policyopen_in_new

Coverage Summary

Medical-Necessity Criteria and Application

Provider Actions and Requirements

Coding

Background

Revision History