D5924 — Cranial prosthesis
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- Refer to the InterQual ® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling for medical necessity clinical coverage criteria.
- Reference and verify the member specific benefit plan document when determining coverage (the member specific benefit plan governs in the event of a conflict).
- Prescription is required for cranial orthoses per FDA Class II device controls (device labeling requires prescription use).
Key Coverage Criteria
- Cranial orthotic devices are proven and medically necessary for treating infants following craniosynostosis surgery
- Cranial orthotic devices are proven and medically necessary for ... nonsynostotic (nonfusion) deformational or positional plagiocephaly
- For medical necessity clinical coverage criteria, refer to the InterQual ® CP: Durable Medical Equipment, Orthoses, Cranial Remodeling.
- FDA: "They are intended for medical purposes to apply pressure to prominent regions of an infant's cranium in order to improve cranial symmetry and/or shape in infants from 3 to 18 months of age, with moderate to severe nonsynostotic positional plagiocephaly, including infants with plagiocephalic-, brachycephalic-, and scaphocephalic-shaped heads."
3 Active Policies
UHC-POL-plagiocephaly-craniosynostosis-treatment — Plagiocephaly and Craniosynostosis Treatment
UMR-POL-UMR-plagiocephaly-craniosynostosis-treatment — Plagiocephaly and Craniosynostosis Treatment
SUREST-POL-SUREST-plagiocephaly-craniosynostosis-treatment — Plagiocephaly and Craniosynostosis Treatment
Related Codes
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