CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthoses)

This policy addresses adjustable cranial remodeling orthoses (bands/helmets) for infants with cranial deformities. Coverage is medically necessary for postoperative management after endoscopic craniosynostosis repair, as an adjunct to surgical treatment of synostotic deformity, and as reconstructive treatment for non-synostotic plagiocephaly/scaphocephaly/brachycephaly when the infant is 3–12 months old, has failed at least 2 months of conservative therapy (e.g., physical therapy for cervical motion restriction or repositioning), and meets policy-defined anthropometric severity criteria. Not covered when criteria are not met, for initial application at >12 months of age, for continued use after 18 months, or for non-surgical treatment of synostotic deformities deemed cosmetic.

"The use of an adjustable cranial orthosis is consideredmedicallynecessaryin the post-operative management of infants following endoscopic repair of craniosynostosis."