L0112 — Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
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."
- Knee braces (children/congenital): Q65.81 - Q65.9; Q66.8; Q68.2; Q72.00 - Q72.93; Q74.1 - Q74.2 - Congenital deformities/reduction defects of lower limb including knee
- An orthosis (orthopedic brace) and/or prosthesis is medically necessary when: care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe orthotics and/or prosthetics according to State law; and the orthosis or prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADL's); and the member’s participating physician or licensed health care practitioner has determ [...]
5 Active Policies
AETNA-CPB-0009 — Orthopedic Casts, Braces and Splints
UHC-POL-plagiocephaly-craniosynostosis-treatment — Plagiocephaly and Craniosynostosis Treatment
ANTHEM-GL-C159218 — CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthoses)
UMR-POL-UMR-plagiocephaly-craniosynostosis-treatment — Plagiocephaly and Craniosynostosis Treatment
Related Codes
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