CurrentUnitedHealthcarePolicy CS095KS.02

Plagiocephaly and Craniosynostosis Treatment (for Kansas Only)

Medical policy governing coverage and documentation expectations for plagiocephaly and craniosynostosis treatment for UnitedHealthcare members in Kansas, including references to related surgical and DME policies.

Policy Summary

PayerUnitedHealthcare

PolicyPlagiocephaly and Craniosynostosis Treatment (for Kansas Only)

Policy CodePolicy CS095KS.02

Change TypeDocumentation expansionreferences updated

Effective DateFeb 1, 2026

Next Review Date

Key ActionProvide complete, legible medical records demonstrating medical necessity (history, physical exam, and pertinent diagnostic results) and make them available upon request.

SourceLink

POLICY UPDATE CHANGES

Added detailed medical records documentation language specifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required to assess clinical criteria.

Added explicit list of documentation elements required to support medical necessity (relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures).

Updated References section to reflect most current information and archived previous policy version CS095KS.01.

Kansas-onlyapplicability

3–18 monthsage range

4codes listed

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Governance and cross-reference criteria

Coverage and medical necessity for plagiocephaly and craniosynostosis treatment are governed by Kansas-specific references and related UnitedHealthcare policies.

Primary governance: Medical necessity criteria for cranial orthoses and plagiocephaly treatment follow the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Provider Manual.

See referenced manual for specific clinical thresholds and criteria

Surgical treatment: Surgical repair for craniosynostosis (CPT 21175) is governed by the UnitedHealthcare policy 'Cosmetic and Reconstructive Procedures (for Kansas Only)'.

Refer to that policy for surgical coverage criteria.

Repair/replacement: Repair or replacement of cranial orthoses is governed by the UnitedHealthcare policy 'Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Kansas Only)'.

Refer to that policy for repair/replacement rules.

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. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws that may require coverage for a specific service.

The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claim payment. Providers should verify coverage and payment with the applicable benefit plan and follow any additional policy or claim submission requirements.

Codes, Age Indications, and Device Classification

Listed HCPCS/CPT/Dental 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).

inv-05: Age indication — 3–18 months

Age indicationIntended use: infants 3–18 months of age

Clinical contextFor moderate to severe nonsynostotic positional plagiocephaly (including plagiocephalic, brachycephalic, and scaphocephalic heads)

Regulatory classificationFDA Class II device (special controls: prescription use, biocompatibility, labeling)

Prior Authorization, Cross-Policy References, and Required Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required when applicable by the member's benefit plan and state program rules. Providers should obtain any required prior authorization from UnitedHealthcare before performing services covered under this policy. In Kansas, refer to the Kansas Medical Assistance Program and applicable state rules for prior authorization and cross-policy requirements.

Prior authorization required when service triggers plan/state prior auth rules
See related policies for surgical repair (CPT 21175) and orthoses repairs/replacements

Note

Provider Action — Submit Required Documentation

Providers must submit supporting clinical documentation with any authorization or claim submission as requested by UnitedHealthcare. Ensure the member’s chart and submitted documents clearly describe the clinical indication and demonstrate how the requested service meets applicable coverage criteria.

Submit documentation with authorization and/or claim submissions as requested
Include clear clinical indication and linkage to coverage criteria

Documentation Required

Required Medical Records

Medical records must fully support the medical necessity for the requested services. Required documentation includes, but is not limited to: relevant medical history, findings from 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.

Relevant medical history supporting diagnosis and treatment rationale
Detailed physical examination findings
Results of pertinent diagnostic tests or imaging
Notes showing prior conservative management if applicable
Treatment plan and expected duration/outcomes

Denial Risk

Documentation-Related Denial Risk

Failure to provide the requested medical records or adequate documentation to support medical necessity may result in denial of the request or payment. Providers are responsible for retaining complete records and producing them upon UnitedHealthcare request to avoid claim denials or delays.

Incomplete or missing documentation may lead to denial of authorization or claim payment
Legible, timely submission of records reduces risk of denial

DME Medical Necessity Guidance

DME medical necessity guidance — Kansas DME manual and FDA context

Refer to the Kansas Medicaid DME manual for specific medical necessity criteria; FDA intended use provides clinical context for typical indications.

FDA intended use: Cranial orthoses are intended for infants 3 to 18 months with moderate to severe nonsynostotic positional plagiocephaly to improve cranial symmetry and/or shape.age 3–18 months

Use as clinical context; actual coverage determined by the Kansas DME manual.

Rental, Purchase, and Related Device Rules

Item	HCPCS/CPT/Dental Code	Description	Coverage
Cranial remolding orthotic (pediatric), custom fabricated
S1040
Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s).
Refer to policy/manual
Cranial prosthesis
D5924
Cranial prosthesis.
Refer to policy/manual
Cranial cervical orthosis, congenital torticollis type, custom fabricated
L0112
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated.
Refer to policy/manual
Cranial cervical orthotic, prefabricated
L0113
Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment.
Refer to policy/manual

Replacement and Repair Guidance

inv-14: Cranial orthoses — replacement-related key values

Replacement governanceRepair or replacement of cranial orthoses is governed by the UnitedHealthcare policy 'Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Kansas Only)'

Prior authorization cross-referenceRefer to the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Provider Manual for medical necessity clinical coverage criteria

Related surgical policySurgical repair (CPT 21175) governed by 'Cosmetic and Reconstructive Procedures (for Kansas Only)'

Documentation Requirements for Medical Necessity

Documentation Required

Provide complete medical records demonstrating medical necessity

Provide complete, legible medical records demonstrating medical necessity for DME requests; these records must include relevant history, physical exam, and results of pertinent diagnostic tests or procedures and be made available upon request.

Ensure all supporting documentation is in the patient's medical record before submission.
Maintain records so they can be produced if requested for review.

Background and Device Context

A cranial orthosis (cranial remolding orthotic or cranial prosthesis) is an FDA Class II device intended to apply pressure to prominent regions of an infant's cranium to improve cranial symmetry and/or head shape. These devices are typically used in infants approximately 3–18 months of age for moderate to severe nonsynostotic positional plagiocephaly (including plagiocephalic, brachycephalic, and scaphocephalic head shapes). Surgical repair for craniosynostosis is governed separately by the Cosmetic and Reconstructive Procedures policy.