CurrentUnitedHealthcarePolicy CS095ID.B

Plagiocephaly and Craniosynostosis Treatment (for Idaho Only)

State-specific UnitedHealthcare medical policy governing coverage references and routing for plagiocephaly and craniosynostosis treatment in Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyPlagiocephaly and Craniosynostosis Treatment (for Idaho Only)

Policy CodePolicy CS095ID.B

Change TypeMaterial updates to clinical routing and removed prior broad coverage language

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionRefer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6 for medical necessity clinical coverage criteria and any prior authorization requirements for cranial remolding orthoses.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6: Cranial Remolding Orthosis for medical necessity clinical coverage criteria for plagiocephaly and craniosynostosis treatment.

Removed language indicating cranial orthotic devices are proven and medically necessary for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly.

Removed reference to the InterQual® CP: Durable Medical Equipment, Orthoses, Cranial Remolding for medical necessity clinical coverage criteria.

Removed the Medical Records Documentation Used for Reviews section from Supporting Information.

Idaho-onlyGeographic

Ch. 6.6Handbook reference

CPT 21175Surgical code

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Coverage Criteria and Scope

Medical necessity criteria reference

Clinical coverage criteria are determined by the Idaho Medicaid Provider Handbook rather than defined in this policy.

Referenced criteria: Refer to Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6: Cranial Remolding Orthosis for medical necessity clinical coverage criteria for plagiocephaly and craniosynostosis treatment.

This policy does not provide specific Boolean criteria; it defers to the Handbook.

This policy previously included language asserting that cranial orthotic devices were proven and medically necessary for certain indications. That language has been removed. Clinical coverage and medical necessity determinations for cranial orthoses are no longer stated in this policy and instead must follow the Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6: Cranial Remolding Orthosis.

Prior policy wording that characterized cranial orthotic devices as proven and medically necessary for treatment of infants after craniosynostosis surgery or for nonsynostotic (deformational/positional) plagiocephaly has been removed. Providers should not rely on this document alone for determinations of medical necessity for these post‑surgical or nonsynostotic conditions; follow the Idaho Medicaid Handbook, Chapter 6.6.

Referenced Procedure and Supply Codes

Referenced HCPCS/Other 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 CPT CodesCPT

21175

Craniosynostosis repair (referenced for surgical treatment guidance)

Provider Requirements and Routing

Prior Authorization

Provider Requirements and Routing

Refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6: Cranial Remolding Orthosis for medical necessity clinical coverage criteria and prior authorization routing for plagiocephaly and craniosynostosis treatment. Coverage/payment may be denied if federal, state, or contractual requirements for benefit plan coverage are not met; in the event of conflict, those requirements govern. For surgical repair of craniosynostosis (CPT 21175), see the Medical Policy titled Cosmetic and Reconstructive Procedures (Idaho only). For repair or replacement of cranial orthoses, see the Medical Policy titled Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (Idaho only). UnitedHealthcare may use external criteria (for example, InterQual®) to assist in administration; providers must follow applicable federal, state, and contractual rules.

Prior authorization and medical necessity decisions: follow Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6: Cranial Remolding Orthosis.
Denial triggers: coverage/payment may be denied if federal, state, or contractual requirements are not met; handbook criteria govern clinical coverage.
Provider actions: check and comply with Idaho-specific prior authorization and documentation routing before submitting claims.
Documentation routing: the Medical Records Documentation section was removed from this policy — providers must follow Idaho Medicaid Handbook and related guidance for documentation and submission requirements.

Medical Necessity References

DME medical necessity reference

Medical necessity criteria for cranial orthoses are defined in the Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6.

Handbook-defined criteria: Follow Idaho Medicaid Provider Handbook, Chapter 6.6 for indications, age ranges, severity thresholds, and fitting/adjustment requirements for cranial remolding orthoses.

This policy defers to the Handbook for all DME medical necessity determinations.

Rental, Purchase, and Billing Rules

Item	Rule / Instruction
Cranial remolding orthosis (S1040); cranial prosthesis (D5924); related cranial cervical orthoses (L0112, L0113)
Refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6 for medical necessity clinical coverage criteria and for guidance on rental vs. purchase, repair, and replacement rules.

Replacement and Repair Guidance

Replacement — cranial orthoses

Referenced HCPCS/S-codes for cranial orthosesD5924, L0112, L0113, S1040 (see Applicable Codes)

Replacement/repair policy referenceRefer to Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Idaho Only) for repair and replacement intervals and rules

Surgical repair referenceFor surgical treatment (CPT 21175), refer to Cosmetic and Reconstructive Procedures (for Idaho Only)

Handbook routing for medical necessityFollow Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6 for clinical criteria that govern replacement decisions

Background and Device Classification

Cranial orthoses are FDA‑classified Class II medical devices designed to apply directed pressure to prominent regions of an infant’s cranium to improve cranial symmetry and shape. These devices are intended for use within the infant age range and clinical scenarios described by the treating payer and clinical guidance (for Idaho, see the Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6).

Key Definitions

Definition — Cranial orthoses

FDA device classificationCranial orthoses are classified by the FDA as Class II devices

Intended purposeIntended to apply pressure to prominent regions of an infant's cranium to improve cranial symmetry and/or shape

Typical age rangeUsed in infants approximately 3 to 18 months of age

Indication/severityIndicated for moderate to severe nonsynostotic positional plagiocephaly, including plagiocephalic, brachycephalic, and scaphocephalic head shapes

Regulatory controlsSubject to special controls including prescription use, biocompatibility testing, and required labeling (contraindications, warnings, precautions, adverse events, instructions)

Documentation Requirements

Documentation Required

Documentation — follow Idaho Medicaid Handbook for required records

The policy removed the standalone 'Medical Records Documentation Used for Reviews' section; providers must follow the Idaho Medicaid Provider Handbook and related DME/orthotics policy for required medical records and documentation used in coverage reviews.

Submit documentation as specified by Idaho Medicaid Chapter 6.6 when requesting coverage or prior authorization for cranial orthoses.
Use the Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements policy for repair/replacement documentation requirements.

Exclusions and Not Covered Items

This policy does not list explicit Durable Medical Equipment exclusions. Language that previously stated broad medical necessity for cranial orthoses in post‑surgical craniosynostosis cases or for nonsynostotic positional plagiocephaly was removed; therefore, coverage determinations must be made using the Idaho Medicaid Provider Handbook, Suppliers, Chapter 6.6 and applicable federal, state, and contract requirements.