This version of the policy will become effective 04/20/2020. This policy was updated with criteria clarification regarding cranial index measurements. Units of measurement were added to the cephalic index table.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Chan JW, Stewart CL, Stalder MW, et al. Endoscope-assisted versus open repair of craniosynostosis: a comparison of perioperative cost and risk. J Craniofac Surg. 2013;24(1):170-174.
Collett BR, Gray KE, Starr Jr. Development at age 36 months in children with deformational plagiocephaly. [American Academy of Pediatrics Web site]. 01/01/2013. Available at: http://pediatrics.aappublications.org/content/131/1/e109.full.pdf+html. Accessed December 06, 2019.
Committee for the assessment of the NIOSH head-and-face anthropometric survey of US respirator users (2014). Anthropometric measurements. pgs. 29-42. [The National Academies Press Web site]. Available at: https://www.nap.edu/read/11815/chapter/4. Accessed December 06, 2019.
Congress of Neurological Surgeons (CNS). Congress of neurological surgeon systematic review and evidence-based guideline on the management of patients with positional plagiocephaly: the role of cranial molding orthosis (helmet) therapy for patients with positional plagiocephaly. [CNS Web site]. 2016. Available at: https://www.cns.org/guidelines/browse-guidelines-detail/5-role-of-cranial-molding-orthosis-helmet-therap. Accessed December 06, 2019.
Couture DE, Crantford JC, Somasundaram A, et al. Efficacy of passive helmet therapy for deformational plagiocephaly: report of 1050 cases. Neurosurg Focus.2013;35(4):E4.
Farkas LG, Munro IR, editoris. Anthropomorphic facial proportions in medicine. 1st. edition. Springfield, IL: Charles C. Thomas;1987.
Fowler EA, Becker DB, Pilgram TK, et al. Neurologic findings in infants with deformational plagiocephaly. J Child Neurol. 2008;23(7):742-747.
Gociman B, Marengo J, Ying J, et al. Minimally invasive strip craniectomy for sagittal synostosis. J Craniofac Surg. 2012;23(3):825-828.
Goldson E, Kelly DP. Developmental-behavior aspects of chronic conditions. In Wolraich ML, Drotar DD, Dworkin PH, Perrin EC eds. Developmental-behavioral pediatrics: evidence and practice. St. Louis, MO; Mosby; 2008:301-404.
Graham JM, Jr., Gomez M, Halberg A, et al. Management of deformational plagiocephaly: repositioning versus orthotic therapy. J Pediatr.2005;146(2):258-262.
Honeycutt JH. Endoscopic-assisted craniosynostosis surgery. Semin Plast Surg.2014;28(3):144-149.
Hutchison BL, Hutchison LA, Thompson JM, Mitchell EA. Quantification of plagiocephaly and brachycephaly in infants using a digital photographic technique. Cleft Palate Craniofac J. 2004;42(5):539-547.
Hutchison BL, Thompson JM, Mitchell A. Determinants of nonsynostotic plagiocephaly: a case-control study. Pediatrics. 2003;112(4):e316. Also available on the Pediatrics Web site at: http://pediatrics.aappublications.org/cgi/reprint/112/4/e316. Accessed December 06, 2019.
Jimenez DF, Barone CM, Cartwright CC, et al. Early management of craniosynostosis using endoscopic-assisted strip craniectomies and cranial orthotic molding therapy. Pediatric. 2002;110(1 Pt 1):97-104.
Jimenez DF, Barone CM. Early treatment of anterior calvtimes craniosynostosis using endoscopic-assisted minimally invasive techniques. Childs Nerv Syst. 2007;23(12):1411-1419.
Jimenez DF, Barone CM. Endoscopic technique for sagittal synostosis. Childs Nerv Syst.2012;28(9):1333- 1339.
Jimenez DF, Barone CM. Multiple-suture nonsyndromic craniosynostosis: early and effective management using endoscopic techniques. J Neurosurg Pediatr.2010;5(3):223-231.
Jimenez DF, Barone CM, McGee ME, et al. Endoscopy-assisted wide-vertex craniectomy, barrel stave osteotomies, and postoperative helmet molding therapy in the management of sagittal suture craniosynostosis. J Neurosurg. 2004; 100(5 Suppl Pediatrics):407-417.
Kaufman BA, Muszynski CA, Matthews A, et al. The circle of sagittal synostosis surgery. Semin Pediatr Neurol. 2004;11(4):243-248.
Kelly KM, Littlefield TR, Pomatto JK, et al. Cranial growth unrestricted during treatment of deformational plagiocephaly. Pediatr Neurosurg. 1999;30(4):193-199.
Kluba S, Kraut W, Calgeer B, et al. Treatment of positional plagiocephaly--helmet or no helmet? J Craniomaxillofac Surg. 2014;42(5):683-688.
Laughlin J, Luerrsen TG, Dias MS. Prevention and management of positional skull deformities in infants. Pediatrics.2011; 128(6):1236-41.
Loveday BP, de Chalain TB. Active counterpositioning or orthotic device to treat positional plagiocephaly? J Craniofac Surg.2001;12(4):308-313.
Losee JE, Mason AC. Deformational plagiocephaly: diagnosis, prevention, and treatment. Clin Plast Surg. 2005;32(1):53-64.
McGarry A, Dixon MT, Greig RJ, et al. Head shape measurement standards and cranial orthoses in the treatment of infants with deformational plagiocephaly. Dev Med Child Neurol. 2008;50(8):568-576.
Miller RI, Clarren SK. Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics.2000;105(2):E26.
Mulliken JB, Vander Woude DL, Hansen M, et al. Analysis of posterior plagiocephaly: deformational versus synostotic. Plast Reconstr Surg. 1999;103(2):371-380.
National Institute of Neurological Disorders and Stroke [NINDS Website]. 2017. Craniosynostosis Information Page. Available at: https://www.ninds.nih.gov/Disorders/All-Disorders/Craniosynostosis-Information-Page. Accessed December 06, 2019.
NHS Quality Improvement Scotland. The use of cranial orthosis treatment for infant deformational plagiocephaly. Evidence Note No. 16. 2007.
Panchal J, Amirsheybani H, Gurwitch R, et al. Neurodevelopment in children with single-suture craniosynostosis and plagiocephaly without synostosis. Plast Reconstr Surg.2001;108(6):1492-1498; discussion 1499-1500.
Peitsch WK, Keefer CH, LaBrie RA, Mulliken JB. Incidence of cranial asymmetry in healthy newborns. Pediatrics. 2002;110(6):e72. Also available on the Pediatrics Web site at: http://pediatrics.aappublications.org/cgi/content/full/110/6/e72. Accessed December 06, 2019.
Persing J, James H, Swanson J, et al. Prevention and management of positional skull deformities in infants. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery and Section on Neurological Surgery. Pediatrics.2003;112(1 Pt 1):199-202.
Persing J, James H, Swanson J, Kattwinkel, J. Prevention and management of positional skull deformities in infants. Pediatrics. 2003;112(1 Pt 1):199-202.
Persing JA. MOC-PS(SM) CME article: management considerations in the treatment of craniosynostosis. Plast Reconstr Surg.2008;121(4 Suppl):1-11.
Shah MN, Kane AA, Petersen JD, et al. Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children's Hospital experience. J Neurosurg Pediatr. 2011;8(2):165-170.
Shamji MF, Fric-Shamji EC, Merchant P, et al. Cosmetic and cognitive outcomes of positional plagiocephaly treatment. Clin Invest Med. 2012;35(5):E266.
Stevens PM, Hollier LH, Stal S. Post-operative use of remoulding orthoses following cranial vault remodelling: a case series. Prosthet Orthot Int. 2007;31(4):327-341.
Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics.2011;128(5):1030-1039.
US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Boston Band Cranial Remolding Orthosis. 510(k) summary. [FDA Web site]. 01/22/08. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf7/K072862.pdf. December 06, 2019.
US Food and Drug Administration (FDA). Center for Devices and Radiological Health. CranioCap™ Cranial Orthosis. 510(k) summary. [FDA Web site]. 01/13/2014. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=k000861. Accessed December 06, 2019.
US Food and Drug Administration (FDA). Center for Devices and Radiological Health. O&P Cranial Molding Helmet®. 510(k) summary. [FDA Web site]. 12/22/06. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf6/K063395.pdf. Accessed December 6, 2019.
US Food and Drug Administration (FDA). Center for Devices and Radiological Health. OPI Band. 510(k) summary. [FDA Web site]. 07/07/2000. Available at:
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?id=k001167. Accessed December 6, 2019.
US Food and Drug Administration (FDA). Center for Devices and Radiological Health. STARlight® Cranial Remolding Orthosis. 510(k) summary. [FDA Web site]. 10/31/08. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf8/K082945.pdf. Accessed December 6, 2019.
Van Vlimmeren LA, Van der Graaf Y, et.al. Effect of pediatric physical therapy on deformational plagiocephaly in children with positional preference: A randomized controlled trial. Arch Pediatr Adolesc Med. 2008;162(8):712–718.
Van Wijk RM, van Vlimmeren LA, Groothuis-Oudshoorn CG, et al. Helmet therapy in infants with positional skull deformation: randomised controlled trial. BMJ. 1 2014;348:g2741.
Wilbrand JF, Seidl M, et al. A prospective randomized trial on preventative methods for positional head deformity: physiotherapy versus a positioning pillow. The Journal of Pediatrics. 2013;162 (6):1216-1221.
Xia JJ, Kennedy KA, Teichgraeber JF, et al. Nonsurgical treatment of deformational plagiocephaly: a systematic review. Arch Pediatr Adolesc Med.2008;162(8):719-727.
M95.2 Other acquired deformity of head
Q67.4 Other congenital deformities of skull, face, and jaw
Q75.8 Other specified congenital malformations of skull and face bones
Q75.9 Congenital malformation of skull and face bones, unspecified
Z98.890 Other specified postprocedural states