CurrentUnitedHealthcarePolicy 2026T0031GG

Plagiocephaly and Craniosynostosis Treatment – Commercial and Individual Exchange Medical Policy

Defines UnitedHealthcare Commercial and Individual Exchange coverage stance for cranial orthotic devices used for infants with craniosynostosis post-surgery and for nonsynostotic (deformational/positional) plagiocephaly, and references InterQual durable medical equipment criteria and related policies for surgery and repairs/replacements.

Policy Summary

PayerUnitedHealthcare

PolicyPlagiocephaly and Craniosynostosis Treatment – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0031GG

Change TypeTemplate Update (no clinical changes)

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders must document that the infant meets the InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling medical necessity criteria when requesting coverage for cranial orthoses.

SourceLink

POLICY UPDATE CHANGES

Template Update created shared policy version to support application to Oxford plan membership and archived previous policy versions 2025T0031FF and SURGERY 114.9.

2Covered indications (post-craniosynostosis surgery; nonsynostotic plagiocephaly)

Coverage Summary

UnitedHealthcare Commercial and Individual Exchange plans are covered under this policy (Plagiocephaly and Craniosynostosis Treatment, Policy Number 2026T0031GG, effective January 1, 2026). The policy defines coverage for cranial orthotic devices for infants following craniosynostosis surgery and for infants with nonsynostotic (deformational/positional) plagiocephaly, with medical necessity determinations made per the InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling criteria.

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UnitedHealthcare relies on InterQual criteria for specific medical necessity thresholds and requires providers to document that the infant meets InterQual criteria when requesting coverage. The policy cross-references related UnitedHealthcare policies for surgical repair of craniosynostosis (see Cosmetic and Reconstructive Procedures for CPT code 21175) and for repair or replacement of cranial orthoses (see Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements).

Policy status: CURRENT. Effective/last review date: January 1, 2026. Administrative/template update noted with no clinical policy statement changes in the 01/01/2026 revision.

Key facts

Policy number2026T0031GG

Coverage stanceCovered with criteria (InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling)

SubjectPlagiocephaly and Craniosynostosis Treatment (cranial orthoses)

Effective dateJanuary 1, 2026

Last reviewJanuary 1, 2026

Covered indications2 (post-craniosynostosis surgery; nonsynostotic plagiocephaly)

Medical Necessity / Coverage Rationale

Coverage Rationale / Medical Necessity

Cranial orthotic devices are considered medically necessary when used for the following situations:

ANY of the following

Treatment of infants following craniosynostosis surgery with a cranial orthotic device
Treatment of infants with nonsynostotic (nonfusion) deformational or positional plagiocephaly with a cranial orthotic device

Reference to clinical criteria: Coverage subject to meeting medical necessity clinical coverage criteria per InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling (refer to InterQual criteria for specific clinical thresholds and details)

HCPCS / Procedure Codes

HCPCS / Procedure Codes ListedHCPCS

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)

Provider Actions & Requirements

Documentation Required

Confirm InterQual criteria

Providers must document that the infant meets the InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling medical necessity criteria when requesting coverage for cranial orthoses.

Prior Authorization

Prior authorization may be required per plan

Coverage and payment are determined by the member-specific benefit plan; medical records may be required to assess whether clinical criteria are met. Follow plan authorization requirements and related UnitedHealthcare DME/orthotics policies for repair/replacement and surgical procedure coding.

Plan-specific prior authorization requirements may apply.
Medical records documentation may be required to verify clinical criteria.
Refer to UnitedHealthcare policies for DME/orthotics repairs and replacements and for surgical coding (e.g., craniosynostosis repair).

Definitions & Background

Cranial orthoses are FDA Class II devices intended for medical use to apply pressure to prominent regions of an infant's cranium to improve cranial symmetry and/or shape in infants typically aged 3 to 18 months with moderate to severe nonsynostotic positional plagiocephaly (including plagiocephalic, brachycephalic, and scaphocephalic head shapes).

Definition: Cranial orthotic devices / cranial orthoses — devices intended to apply pressure to prominent regions of an infant's cranium to improve cranial symmetry and/or shape; FDA classified as Class II (product code MVA).

UnitedHealthcare relies on InterQual CP: Durable Medical Equipment, Orthoses, Cranial Remodeling for medical necessity criteria and thresholds. The policy also cross-references related policies for surgical repair of craniosynostosis and for repair/replacement of cranial orthoses.

Revision History

2026-01-01revisedLatest

Template Update created shared policy version to support application to Oxford plan membership; archived previous policy versions 2025T0031FF and SURGERY 114.9.