Anthem Blue Cross Connecticut CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics) Form

This document addresses the use of the adjustable band or helmet cranial orthoses as a treatment of craniosynostosis, non-synostotic plagiocephaly (asymmetrically shaped posterior head), scaphocephaly (abnormally shaped narrow head), and brachycephaly (abnormally shaped head; shortened in antero-posterior dimension without asymmetry) in infants.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.

Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Clinical Indications

Medically Necessary:

The use of an adjustable cranial orthosis is considered medically necessary in the post-operative management of infants following endoscopic repair of craniosynostosis.

The use of cranial orthoses is considered medically necessary as an adjunct to surgical treatment of synostotic skull deformity.

Reconstructive:

1. The initial use of cranial orthoses is considered reconstructive to treat non-synostotic skull deformity (including plagiocephaly, scaphocephaly, and brachycephaly) when the individual meets ALL the following criteria (A and B and C):
   1. The infant is at least three (3) months of age but not greater than twelve (12) months of age; and
   2. Documented failure of at least two (2) months of conservative therapy which includes either (1) or (2) below:
      1. Two (2) months of physical therapy for infants with associated cervical motion restriction, including initial and final assessment of range of motion; or
      2. Two (2) months of home management with repositioning for infants without cervical motion restriction; and
   3. Anthropomorphic measurements (see Definitions section) following conservative management with final measurements indicating ONE of the following:
      1. Cephalic index measurement is ONE of the following:
         1. 0-3 months of age: less than 75% or greater than 95%; or
         2. 4-6 months of age: less than 74% or greater than 94%; or
         3. 7-12 months of age: less than 73% or greater than 93%; or
      2. Cranial vault asymmetry index greater than 3.5%; or
      3. Oblique diameter difference index greater than 108%; or
      4. Cranioproportional index of plagiocephelometry greater than 95%.
2. A second application of the cranial orthosis is considered reconstructive for infants between six (6) and eighteen (18) months of age when all the following criteria (A and B and C) have been met:
   1. Final post-therapy anthropomorphic measurements (see Definitions section) indicating ONE or more of the following:
      1. Cephalic index measurement is ONE of the following:
         1. 4-6 months of age: less than 74% or greater than 94%; or
         2. 7-12 months of age: less than 73% or greater than 93%; or
         3. 13-18 months of age: less than 72% or greater than 92%; or
      2. Cranial vault asymmetry index greater than 3.5%; or
      3. Oblique diameter difference index greater than 108%; or
      4. Cranioproportional index of plagiocephelometry greater than 95%; and
   2. One of the following (1 or 2):
      1. For infants with associated cervical motion restriction, documentation of physical therapy or home exercise program with interval assessment of range of motion since the initial orthotic application; or
      2. For infants without cervical motion restriction, at least two (2) months of home management with repositioning either before or after the initial application; and
   3. If a new orthosis is being requested, documentation of skin complications or inadequate therapeutic positioning due to head growth that cannot be managed or prevented with refitting of the original orthosis, when continued improvement is anticipated.

Not Medically Necessary:

The use of cranial orthoses is considered not medically necessary when criteria have not been met.

Initial application of cranial orthosis for infants over the age of twelve (12) months is considered not medically necessary.

Continued use of cranial orthosis after eighteen (18) months of age is considered not medically necessary.

Cosmetic and Not Medically Necessary:

The use of cranial orthoses is considered cosmetic and not medically necessary for non-surgical treatment of synostotic skull deformities.