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An asymmetrically shaped head may be synostotic or nonsynostotic. Synostosis, defined as premature closure of the sutures of the cranium, may result in functional deficits secondary to increasing intracranial pressure in an abnormally or asymmetrically shaped cranium. The type and degree of craniofacial deformity depends on the type of synostosis. The most common is scaphocephaly, which describes a narrowed and elongated head resulting from synostosis of the sagittal suture, while premature fusion of the metopic suture results in a triangular shape of the forehead known as trigonocephaly. Unilateral synostosis of the coronal suture results in an asymmetric distortion of the forehead termed plagiocephaly, and fusion of both coronal sutures results in brachycephaly. Combinations of these may also occur. Synostotic deformities associated with functional deficits are addressed by surgical remodeling of the cranial vault. The remodeling (reshaping) is accomplished by opening and expanding the abnormally fused bone.

Plagiocephaly without synostosis, also called positional or deformational plagiocephaly, can be secondary to various environmental factors including, but not limited to, premature birth, restrictive intrauterine environment, birth trauma, torticollis, cervical anomalies, and sleeping position. Positional plagiocephaly typically consists of right or left occipital flattening with advancement of the ipsilateral ear and ipsilateral frontal bone protrusion, resulting in visible facial asymmetry. Occipital flattening may be self-perpetuating, in that once it occurs, it may be increasingly difficult for the infant to turn and sleep on the other side. Bottle feeding, a low proportion of “tummy time” while awake, multiple gestations, and slow achievement of motor milestones may contribute to positional plagiocephaly. The incidence of plagiocephaly has increased rapidly in recent years; this is believed to be a result of the “Back to Sleep” campaign recommended by the American Academy of Pediatrics, in which a supine sleeping position is recommended to reduce the risk of sudden infant death syndrome (SIDS). It is hoped that increasing awareness of identified risk factors and early implementation of good practices will reduce the development of deformational plagiocephaly. It is estimated that about two-thirds of cases may correct spontaneously after regular changes in sleeping position or following physiotherapy aimed at correcting neck muscle imbalance. A cranial orthotic device is usually requested after a trial of repositioning fails to correct the asymmetry, or if the child is too mobile for repositioning.

Use of an adjustable cranial orthosis for synostosis in the absence of cranial vault remodeling surgery is considered not medically necessary.

An adjustable cranial orthosis as a treatment of plagiocephaly or brachycephaly without synostosis is considered not medically necessary.

None

Assessment of plagiocephaly in research studies may be based on anthropomorphic measures of the head, using anatomical and bony landmarks. However, there is no accepted minimum objective level of asymmetry for a plagiocephaly diagnosis. The following table presents normative values and the mean pretreatment asymmetries reported in large case series. These may be useful in determining if a significant variation from normal is present.

*In this report, the asymmetry was measured from the tragus to the frontozygomatic point instead of the excanthion.

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

8/2000: Reviewed by Medical Policy Advisory Committee (MPAC), investigational status maintained.

10/17/2001: Sources and Code Reference sections updated

2/11/2002: Investigational definition added

4/26/2002: Type of Service and Place of Service deleted

9/20/2002: Policy statement revised

10/11/2002: HCPCS S1040 added

5/20/2004: Code Reference section updated, CPT code 97799 deleted, HCPCS L0100, L0110 description revised

6/24/2004: Policy reviewed, Description section revised to be consistent with BCBSA policy # 1.01.11

8/5/2005: Code Reference section updated, ICD-9 procedure code 93.29 deleted

3/22/2006: Coding updated. CPT4 2006 revisions added to policy

3/28/2006: Policy reviewed, no changes

12/27/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions

4/24/2007: Policy reviewed, no changes

12/22/2008: Policy reviewed, the following removed from the policy statement, "As an adjunctive postsurgical therapy for synostotic plagiocephaly, dynamic orthotic cranioplasty is considered investigational."

06/23/2010:  Policy title changed from “Adjustable Banding as a Treatment of Plagiocephaly” to “Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses.” Policy description updated regarding treatment approaches and craniosynostoses. Added policy statements on craniosynostoses, which is considered medically necessary following cranial vault remodeling surgery. Reworded policy statement regarding nonsynostotic plagiocephaly/ brachycephaly; intent unchanged. Deleted outdated references from the Sources section. Based on the medically necessary policy statement, moved 97762 and S1040 from non-covered to covered. ICD-9 code 754.0 removed from the codes table as this indication remains non-covered. Removed deleted CPT code L0100 and L0110 from the codes table as they were deleted on 12/31/2006.

06/08/2011: Policy reviewed; no changes.

04/19/2012: Policy reviewed; no changes.

04/19/2013: Policy reviewed; no changes.

Blue Cross & Blue Shield Association Policy #1.01.11

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes  

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