Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Treatments for head asymmetry or misshapenness in babies are generally considered to be cosmetic; however, there may be unusual circumstances when it is considered medically necessary.

QualChoice/QCA considers the use of a cranial remodeling band (or of a cranial remodeling helmet) as durable medical equipment.  The use of these techniques to change infant head shape is held to be medically necessary for moderate to severe positional head deformities associated with premature birth, restrictive intrauterine positioning, cervical abnormalities, birth trauma, torticollis (shortening of the sternocleidomastoid muscle) and sleeping positions in children when banding is initiated at 4 to 12 months of age and the following conditions are met:

1. A 2-month trial of conservative therapy consisting of repositioning the child`s head such that the child lies opposite to the preferred position, has failed to improve the deformity and is judged to be unlikely to do so, and
2. One of the following must be met:
   1. Anthropometric data (measurements used to evaluate abnormal head shape by measuring the distance in mm from one pre-designated point on the face or skull to another, comparing the right and left sides) verifies that a moderate to severe plagiocephaly is documented by a physician experienced in such measurement. (Note: These measurements are generally obtained by the orthotist fitting the band or helmet.) The most significant measurements used in this initial evaluation are skull base asymmetry, cranial vault asymmetry, orbitotragial depth, and cephalic index.

DIAGRAM:

A difference of asymmetry greater than 6 mm between anthropometric measurements (see diagram above) in any of the anthropometric data in the first column of the following table warrants coverage of a trial of orthotic banding to correct the craniofacial deformity:

1. For brachycephaly evaluation, a cephalic index 2 standard deviations below mean (head narrow for its length) or 2 standard deviations above mean (head wide for its length) warrants coverage of a trial of orthotic banding to correct the craniofacial deformity in a child after 4 months of age and before 12 months of age. (Note: These measurements are generally obtained by the orthotist fitting the band or helmet.)

1. Premature infants with dolichocephalic head shape who have developed a misshapen head secondary to sustained head position.
2. Infants who develop significant plagiocephaly secondary to a constant head position required for long-term hyperalimentation who do not respond to simple changing of the catheter location allowing the head to be repositioned.
3. Members with moderate to severe residual plagiocephaly after surgical correction.
4. Members with excess frontal bossing secondary to sagittal synostosis.

Codes Used In This BI:

S1040           Cranial Remolding Orthosis

1. Orthomerica Products, Inc. The STARband™ Cranial Remolding Orthosis [website]. Newport Beach, CA: Orthomerica; 2003. Available at: http://www.orthomerica.com/products/cranial/starband.htm. Accessed Sept 7, 2004.
2. Gillette Children`s Specialty Healthcare. Craniocap™ [website]. St. Paul, MN: Gillette; 2003, 2004. Available at: http://www.gillettechildrens.org/  Accessed Sept.7, 2004.
3. Persing J, James H, Swanson J, et al. Prevention and management of positional skull deformities in infants. The American Academy of Pediatrics. Clinical report. Guidance for the clinician in rendering pediatric care. Pediatrics. 2003; 112(1):199-202.
4. Institute for Clinical Systems Improvement (ICSI). Cranial orthoses for deformational plagiocephaly. ICSI Technology Assessment Reports. TA #082. Bloomington, MN: ICSI; March 2004. Available at: http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=1495      Accessed Sept. 7, 2004.

Addendum:

1. Effective 07/01/2017: Removed PA requirement. 4/12/17