C1781 — Mesh (implantable)
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- For post-operative use in synostotic plagiocephaly: documentation of prior surgery for craniosynostosis and continued asymmetry requiring orthotic intervention (no pre-band conservative trial required in this post-op situation).
- Documentation that craniosynostosis is surgically corrected if a band/helmet is to be used post-operatively (uncorrected craniosynostosis is a contraindication).
- For post-operative use in synostotic plagiocephaly: documentation of prior craniosynostosis surgery and continued asymmetry requiring orthotic management (no conservative trial required in this post-operative setting).
- Documentation of any contraindications (e.g., unshunted or uncontrolled hydrocephalus, craniosynostosis not surgically corrected) where orthoses would be contraindicated and not medically necessary.
Key Coverage Criteria
- CPT/HCPCS/ICD-10: coverage is associated with listed CPT/HCPCS codes (e.g., S1040, D5924, L0112, L0113) and ICD-10 codes Q67.2, Q67.3, Q67.4, Q75.0, Q75.1, Q75.8-Q75.9 when selection criteria are met.
- Cranial remodeling bands (or helmets) as medically necessary orthoses for treatment of moderate-to-severe positional head deformities associated with premature birth, restrictive intra-uterine positioning, cervical abnormalities, birth trauma, torticollis (shortening of the sternocleidomastoid muscle) and sleeping positions in children when banding is initiated at 3 to 12 months of age and the following conditions are met: a 2-month trial of conservative therapy consisting of re-positioning the [...]
- A difference of asymmetry greater than 6 mm between anthropometric measurements in any of the anthropometric data (cranial base, cranial vault, orbitotragial depth) warrants coverage of a trial of orthotic banding to correct the craniofacial deformity.
- For brachycephaly evaluation, a cephalic index of 2 standard deviations (SDs) below mean (head narrow for its length) or 2 SDs 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.
- 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 re-positioned.
- Members with excess frontal bossing secondary to sagittal synostosis.
4 Active Policies
CIGNA-0178 — Breast Reconstruction Following Mastectomy or Lumpectomy - (0178)
CIGNA-0068 — Tissue Engineered Skin Substitutes - (0068)
AETNA-CPB-0244 — Skin and Soft Tissue Substitutes
AETNA-CPB-0379 — Cranial Remodeling
Related Codes
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