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Cranial orthoses are usually in the shape of an adjustable helmet or band that progressively molds the shape of the infant cranium by applying corrective forces to prominences while leaving room for growth in the adjacent flattened areas. A cranial orthotic device may be requested for the treatment of positional plagiocephaly or postsurgical synostosis in pediatric patients.
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.
There are a number of devices intended to apply passive pressure to prominent regions of an infant’s cranium to improve cranial symmetry and/or shape in infants from 3 to 18 months of age. These devices have been cleared through the U.S. Food and Drug Administration 510(k) process.
Use of an adjustable cranial orthosis may be considered medically necessary following cranial vault remodeling surgery for synostosis.
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.
Procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment, i.e., improve health outcomes. In this policy document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease, or congenital defect.
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.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/1997: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, CPT code 97799, 97703, ICD-9 procedure code 93.29, ICD-9 diagnosis code 754.0, HCPCS L0100, L0110
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.
07/09/2014: Policy reviewed; no changes.
07/02/2015: Code Reference section updated for ICD-10.
09/16/2015: Policy description updated regarding devices. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions.
05/26/2016: Policy number added.
Blue Cross & Blue Shield Association Policy #1.01.11
CODE REFERENCEThis is not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.