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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 11/03/2004 Title: Cranial Remodeling Bands & Helmets (Plagiocephaly)
Revision Date: 07/01/2017 Document: BI085:00
CPT Code(s): S1040
Public Statement

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.


Medical Statement

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:

Anthropometric Data

Measurement

Measures

Cranial base
(sn-t on same side)

from right and left subnasal point (sn) to tragus (t)

measures maxillary depth or right and left morphological face height

Cranial vault
(fz R-euL, fz L-euR)

from frontozygomaticus point (fz) on one side of face to euryon (eu)

measures cranial vault asymmetry

Orbitotragial depth
(ex-t, R, L)

from exocanthion point (ex) to tragus (t)

measures orbito-tragion depth (exocanthion)

    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.)

Head width
(eu - eu)

from euryon (eu) on one side of head to euryon (eu) on the other side

measures greatest transverse diameter or maximal head width

Head length
(g-op)

from glabella point (g) to opisthocranion (op)

measures maximal head depth or length

Cephalic index = 

Head width (eu - eu) x 100

 

Head length (g - op)

       

 

Sex

Age

-2SD

-1SD

Mean

+1SD

+2SD

Male

16 days to 6 months

63.7

68.7

73.7

78.7

83.7

 

6 - 12 months

64.8

71.4

78.0

84.6

91.2

Female

16 days to 6 months

63.9

68.6

73.3

78.0

82.7

 

6-12 months

69.5

74.0

78.5

83.0

87.5

    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


Background

Plagiocephaly (an asymmetrical head shape) is most often the result of an infant spending extended periods of time on their back, typically during sleep. Plagiocephaly can also occur as a feature of other disorders (e.g., craniofacial disorders, torticollis, and cervical anomalies) and is categorized as either positional or synostotic (premature union of cranial sutures). Although 1 in 300 infants’ exhibit variable degrees of plagiocephaly, true sutural synostosis, which interferes with cranium development and may cause increased intracranial pressure, occurs in only 0.4 to 1 per 1000 live births.

Positional plagiocephaly is treated conservatively and many cases do not require any treatment as the condition may resolve spontaneously when the infant begins to sit up. When the deformity is moderate or severe and a trial of repositioning the infant has failed, a pediatric neurologist, neurosurgeon, or other appropriate specialist in craniofacial deformities may prescribe a cranial remodeling band to remodel the misshapen head.

 

Examples of brands of cranial remodeling bands and helmets include the Dynamic Orthotic Cranioplasty (DOC) Band™, Gillette Children`s Craniocap, and the STARband™ Cranial Headband. Average treatment time with the cranial remodeling band or helmet is four and a half months.


Reference
  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

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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