S1040, Cranial remolding orthosis, pediatric, rigid, with soft interface material,
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Item must be ordered by a physician.
- DME requests must include documentation that the item(s) meets the plan's medically necessary definition and that criteria are met (refer to member specific benefit plan document and InterQual/CMS guidance as applicable).
- Replacement requests must document that equipment is beyond its Reasonable Useful Lifetime (RUL) (standard RUL for DME is five (5) years) and has become Irreparable.
- Repairs: documentation that repair (including replacement of essential accessories) is necessary to make the item/device serviceable.
Key Coverage Criteria
- Durable Medical Equipment (DME) when: ordered or provided by a physician for outpatient use primarily in a home setting; used for medical purposes; not consumable or disposable except as needed for the effective use of covered DME; not of use to a person in the absence of a disease or disability; serves a medical purpose for the treatment of a sickness or injury; primarily used within the home.
- DME, related supplies, and orthotics when ordered by a physician and the item(s) meets the plan's medically necessary definition and criteria are met and the item is not otherwise excluded from coverage.
- Ventilators (mechanical ventilators, HCPCS codes E0465 and E0466) are considered medically necessary to treat neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease in certain clinical scenarios (refer to InterQual Medicare: Post Acute & Durable Medical Equipment, Ventilators NCD for clinical coverage criteria).
- Bi-level positive airway pressure (BiPAP) devices (HCPCS codes E0470 and E0471) are considered medically necessary in certain clinical scenarios (refer to InterQual CP: Durable Medical Equipment, Noninvasive Airway Assistive Devices for clinical coverage criteria).
- BiPAP device with or without backup rate is considered medically necessary in clinical scenarios not excluded by the policy, except as noted under limitations (see BiPAP unproven statements).
- Breast pumps may be covered under the preventive care services benefit (refer to the Medical Policy titled Preventive Care Services).
12 Active Policies
ANTHEM-GL-C159218, CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthoses)
UHC-POL-dme-equipment-orthotics-ostomy-medical-supplies-repairs-replacements, Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements
UHC-POL-plagiocephaly-craniosynostosis-treatment, Plagiocephaly and Craniosynostosis Treatment
DME103.007, Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Related Codes
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