CurrentUnitedHealthcarePolicy CSNCT0031.07

Plagiocephaly and Craniosynostosis Treatment (for North Carolina Only)

Policy governing coverage guidance for cranial orthotic devices and related treatment decisions for plagiocephaly and craniosynostosis for UnitedHealthcare members in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicyPlagiocephaly and Craniosynostosis Treatment (for North Carolina Only)

Policy CodePolicy CSNCT0031.07

Change TypeMaterial wording added to medical records documentation

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionEnsure the patient's medical record contains legible documentation that fully supports medical necessity, including history, exam, and pertinent diagnostic results.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and applicable laws, and that medical records documentation may be required but does not guarantee coverage.

1applicable state

3-18 monthsage range

3policy sections w/ code guidance

Class IIFDA class

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Delegated criteria / cross-referenced coverage

Coverage determinations reference external North Carolina-specific policies.

Delegated coverage logic: Medical necessity clinical coverage criteria for cranial orthotic devices are as specified in the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Medical Equipment: 5B, Orthotics & Prosthetics; surgical treatment to repair craniosynostosis (CPT 21175) is addressed in the Medical Policy titled Cosmetic and Reconstructive Procedures (for North Carolina Only); repair or replacement of cranial orthoses is addressed in the Medical Policy titled Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for North Carolina Only).

Providers must consult the referenced North Carolina Medicaid policies for the specific clinical criteria, coding, and prior authorization requirements.

Codes in the Applicable Codes list that are marked with an asterisk (*) are noted as not on the State of North Carolina Medicaid Fee Schedule. Because these codes are not on the NC Medicaid fee schedule, they may not be covered by the State of North Carolina Medicaid Program. Inclusion of a code in this policy is for reference only and does not guarantee coverage or payment; final coverage and reimbursement depend on applicable federal, state, or contractual requirements and other plan rules.

Benefit coverage decisions may require review of the member’s medical record. The policy states that medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the requested service.

Providers must ensure the patient’s medical record fully supports the medical necessity for the requested cranial orthotic device. Required documentation includes, but is not limited to, relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation should be legible, maintained in the patient’s record, and made available upon request; absence of adequate documentation may lead to denial of the requested services.

Applicable Codes and Coding Guidance

Applicable Codes (reference list)HCPCS

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

Age range for device intent

Device intended age range3 to 18 months

Target populationInfants with moderate to severe nonsynostotic positional plagiocephaly

Included head-shape variantsPlagiocephalic-, brachycephalic-, and scaphocephalic-shaped heads

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Coding References

Prior authorization and coding references: Prior authorization and coding follow NC Medicaid Clinical Coverage Policy 5B (Orthotics & Prosthetics) and applicable UnitedHealthcare prior authorization requirements. For surgical repair of craniosynostosis (CPT 21175) see the Cosmetic and Reconstructive Procedures medical policy (North Carolina only). For repair or replacement of cranial orthoses see the Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements medical policy (North Carolina only). Applicable HCPCS/CPT codes (for reference) include D5924 (cranial prosthesis), L0112, L0113, and S1040. Codes marked with an asterisk in source materials may not be on the NC Medicaid Fee Schedule and may not be covered.

Prior authorization may be required per payer and state-specific policies.
Reference NC Medicaid Clinical Coverage Policy 5B for detailed coding and coverage criteria.
CPT 21175 (surgical repair of craniosynostosis) governed by Cosmetic and Reconstructive Procedures policy.
Repair/replacement of cranial orthoses governed by Durable Medical Equipment and Repairs/Replacements policy.
Reference codes (examples): D5924; L0112; L0113; S1040. Codes with * may not be on NC Medicaid Fee Schedule.

Documentation Required

Required Medical Record Documentation

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. This includes, but is not limited to: relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient’s medical record, and available upon request.

Include relevant medical history and rationale for the cranial orthotic or procedure.
Document physical exam findings that support need (e.g., head shape measurements, severity of deformity).
Attach results of diagnostic tests or imaging when used to justify treatment.
Ensure notes are legible and retained in the member’s medical record.

Denial Risk

Denial Risk When Medical Record Documentation Is Incomplete

Lack of sufficient medical record documentation may result in denial of the request or claim. Coverage determination requires that the member meet the clinical criteria; absence of supporting records does not establish medical necessity and may lead to claim denial or request for additional information.

Denial risk when documentation does not demonstrate clinical need, relevant history, physical exam, or diagnostic testing.
Failure to provide requested records upon review may result in adverse coverage decisions.
Ensure submitted documentation directly ties clinical findings to the requested service.

Note

Provider Actions — Summary

Provider actions summary: Submit prior authorization requests per UnitedHealthcare and state-specific requirements; include complete, legible medical records that document medical necessity; use applicable coding per NC Medicaid Clinical Coverage Policy 5B and referenced UnitedHealthcare policies.

Attach clinical notes, exam findings, and diagnostic test results to authorization requests.
Verify code selection against NC Medicaid fee schedule when applicable.
Respond promptly to requests for additional documentation to avoid processing delays or denials.

OpenPayer

Plagiocephaly and Craniosynostosis Treatment (for North Carolina Only)

Coverage Criteria

Applicable Codes and Coding Guidance

Provider Actions and Requirements

Background

Definitions

Revision History