Cranial Orthosis for Plagiocephaly

Policy ID: O-13-027

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: August 18, 2021

Revision Effective Date: November 01, 2021

Last Reviewed: September 21, 2021

Applies To: Commercial and Medicaid Expansion

Description

A cranial orthosis used in the treatment of plagiocephaly is a device intended for medical purposes to apply pressure to prominent regions of an infant's cranium in order to improve cranial symmetry and/or shape.

Criteria

Non-synostotic Plagiocephaly

Cranial orthotic devices used in the treatment of moderate-to-severe non-synostotic plagiocephaly may be considered medically necessary when ALL of the following criteria are met:

The infant must have tried and failed conservative therapy (i.e., repositioning) for a minimum of two (2) months; and
The infant must be three (3) - 18 months of age; and
Cranial asymmetry is documented by EITHER of the following:
- Moderate to severe plagiocephaly in ONE of the following anthropometric dimensions (Table 1):
  - Cranial vault; or
  - Cranial base; or
  - Orbitotragial depth; or
- Cephalic index measurement is two (2) standard deviations (SD) above or below the mean (Table 2)

Cranial orthosis is considered cosmetic and therefore non-covered when used in the treatment of non-synostotic plagiocephaly with mild deformity and/or when a minimum trial period of two (2) months of conservative therapy has not been tried.

Cranial orthotic devices for non-synostotic plagiocephaly not meeting the criteria as indicated in this policy is considered not medically necessary.

Synostotic Plagiocephaly

Cranial orthotic devices used in the post-operative treatment of synostotic plagiocephaly may be considered medically necessary for infants with moderate to severe residual plagiocephaly after surgical correction when cranial asymmetry is documented by ANY of the following:

Moderate to severe plagiocephaly in ONE of the following anthropometric dimensions (Table 1):
- Cranial vault; or
- Cranial base; or
- Orbitotragial depth; or
Cephalic index measurement is two (2) standard deviations (SD) above or below the mean (Table 2).

Cranial orthotic devices for synostotic plagiocephaly not meeting the criteria as indicated in this policy is considered not medically necessary

Procedure Codes

L0112

L0113

S1040

Determination of Severity of Plagiocephaly

Determination of the severity of plagiocephaly requires precise measurements of the skull using either the
cephalic index or anthropomorphic measurements.

Table 1

Specifications for Taking Anthropometric Measurements

Comparative Cranial Landmarks

Cranial Vault

Left frontozygomatic point (fz) to right euryon (eu) minus right frontozygomatic point (fz) to left euryon (eu)

Cranial Base

Subnasal point (sn) to left tragus (t) minus subnasal pint (sn) to right tragus (t)

Orbitotragial Depth

Left exocanthion point (ex) to left tragus (t) minus right exocanthion point (ex) to right tragus (t)

Moderate to severe plagiocephaly is defined as one of the following:
Cranial base (sn – t): >= 6 mm difference between left and right measurements

Cranial vault (fz – contralateral eu): >= 8 mm difference between left and right measurements

Obitotragial depth (ex – t): >= 4 mm difference between left and right measurements

Table 2

Cephalic index: Head width (eu-eu) x 100

Head length (g-op)

Moderate to severe plagiocephaly is defined as a cephalic index two standard deviations above or below the mean. Infants with deformational scaphocephaly will have a lower cephalic index due to a very long and narrow skull deformity. Infants with deformational brachycephaly will have an increased cephalic index due to a very wide and short skull deformity.

Gender

Age

-2SD

-1SD

Mean

+1SD

+2SD

Male

16 days -
6 months

63.7

68.7

73.7

78.7

83.7

6 – 12 months

64.8

84.6

91.2

Female

16 days -
6 months

63.9

73.3

82.7

6 – 12 months

69.5

78.5

87.5

Assessment of plagiocephaly 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.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes L0112, L0113 and S1040.

Q67.3

Q75.0

Q75.8

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 incorporate Tables into policy

Internal Medical Policy Committee 07-22-2020 Annual Review

Internal Medical Policy Committee 5-20-2021 Annual Review

Internal Medical Policy Committee 9-21-2021 Revised language

Links

References

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: O-13-026

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: November 14, 2019

Last Reviewed: May 20, 2021

Archived Date: October 31, 2021

Applies To: Commercial Only

Description

Criteria

Non-synostotic Plagiocephaly

Cranial orthotic devices used in the treatment of moderate-to-severe non-synostotic plagiocephaly may be considered medically necessary when ALL of the following criteria are met:

The infant must have tried and failed conservative therapy (i.e., repositioning) for a minimum of two (2) months; and
The infant must be 3 - 18 months of age; and
Cranial asymmetry is documented by EITHER of the following:
- Moderate to severe plagiocephaly in ONE of the following anthropometric dimensions (Table 1):
  - Cranial vault; or
  - Cranial base; or
  - Orbitotragial depth; or
- Cephalic index measurement is two (2) standard deviations above or below the mean (Table 2)

Cranial orthosis is considered cosmetic when used in the treatment of non-synostotic plagiocephaly with mild deformity and/or when a minimum trial period of two (2) months of conservative therapy has not been tried. Therefore, these services are non-covered.

Synostotic Plagiocephaly

Moderate to severe plagiocephaly in ONE of the following anthropometric dimensions (Table 1):
- Cranial vault; or
- Cranial base; or
- Orbitotragial depth; or
Cephalic index measurement is two (2) standard deviations above or below the mean (Table 2).

Procedure Codes

L0112

L0113

S1040

Tables:
Determination of Severity of Plagiocephaly
Determination of the severity of plagiocephaly requires precise measurements of the skull using either the cephalic index or anthropomorphic measurements.

Table 1
Specifications for Taking Anthropometric Measurements

Comparative Cranial Landmarks

Cranial Vault

Left frontozygomatic point (fz) to right euryon (eu) minus right frontozygomatic point (fz) to left euryon (eu)

Cranial Base

Subnasal point (sn) to left tragus (t) minus subnasal point (sn) to right tragus (t)

Orbitotragial Depth

Left exocanthion point (ex) to left tragus (t) minus right exocanthion point (ex) to right tragus (t)

Moderate to severe plagiocephaly is defined as one of the following:
Cranial base (sn – t): >= 6 mm difference between left and right measurements

Cranial vault (fz – contralateral eu): >= 8 mm difference between left and right measurements

Obitotragial depth (ex – t): >= 4 mm difference between left and right measurements

Table 2

Cephalic Index:

Head with (eu-eu) x 100

Head length (g - op)

Moderate to severe plagiocephaly is defined as a cephalic index two standard deviations above or below the mean.

Infants with deformational scaphocephaly will have a lower cephalic index due to a very long and narrow skull deformity.

Infants with deformational brachycephaly will have an increased cephalic index due to a very wide and short skull deformity.

Gender

Age

-2SD

-1SD

Mean

+1SD

+2SD

Male

16 days - 6 months

63.7

68.7

73.7

78.7

83.7

6-12 months

64.8

71.4

84.6

91.2

Female

16 days - 6 months

63.9

68.6

73.3

82.7

6-12 months

69.5

78.5

87.5

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.

Table 3

Normative Values

Study

Cranial Base (mm)

Cranial Vault (mm)

Orbitotragial Distance (mm)

Moss (1)

9.2

7.1*

Littlefield et. al. (2)

6.17

8.5

4.36

Teichgreber et. al. (3)

7.08

8.53

3.12

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