Adjustable Banding as a Treatment of Plagiocephaly

Medical Policy: 01.01.05 
Original Effective Date: August 2000 
Reviewed: October 2011 
Revised: June 2010 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy 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 will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Plagiocephaly, which refers to an asymmetrically shaped head, can be subdivided into synostotic and non-synostotic types. Synostotic plagiocephaly describes an asymmetrically shaped head due to premature closure of the sutures of the cranium. In plagiocephaly without synostosis, the sutures remain open. Plagiocephaly without synostosis, also called positional or deformational plagiocephaly, can be secondary to various environmental factors including, but not limited to, premature birth, restrictive intrauterine environment, birth trauma, torticollis, cervical anomalies, and sleeping position. Brachycephaly refers to a head shape that is not asymmetric but is disproportionately short. The incidence of plagiocephaly and brachycephaly has increased rapidly in recent years as a result of the “Back to Sleep” campaign recommended by the American Academy of Pediatrics, in which a supine sleeping position is recommended to reduce the risk of sudden infant death syndrome (SIDS). It is estimated that 1 of every 60 neonates may have some degree of plagiocephaly or brachycephaly. Positional plagiocephaly typically consists of right or left occipital flattening with advancement of the ipsilateral ear and prominence of the ipsilateral frontal region, resulting in visible facial asymmetry. Occipital flattening may be self-perpetuating, in that once it occurs it may be increasingly difficult for the infant to turn and sleep on the other side. Assessment of plagiocephaly and brachycephaly are based on anthropomorphic measures of the head, using anatomical and bony landmarks.

There are 3 basic options for treating plagiocephaly and brachycephaly; no therapy, repositioning therapy, and adjustable banding, which may be referred to as dynamic orthotic cranioplasty (DOC). Repositioning therapy includes supervised “tummy time,” or placement of the child in a half supine position with a towel or blanket roll behind the shoulder to position the occiput away from the flat side. Physical therapy may also be recommended, particularly if there is shortening or tightening of the sternocleidomastoid muscle. Adjustable banding involves use of a custom-molded orthotic, either a helmet or band that can progressively mold the shape of the cranium by applying corrective forces to the frontal and occipital prominences while leaving room for growth in the adjacent flattened areas. Treatment is typically initiated around 5 to 6 months of age, frequently after a prior trial of repositioning therapy, and continues for an average of 4 to 5 months. Both helmets and cranial bands are recommended for wear 23 hours per day, with 1 hour off for skin care and hygiene.

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Prior Approval: 

Not applicable

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Policy: 

• Use of adjustable cranial banding may be considered medically necessary following cranial vault remodeling surgery for synostosis.
• Use of adjustable cranial banding for synostosis in the absence of cranial vault remodeling surgery is considered not medically necessary
• Adjustable cranial banding as a treatment of plagiocephaly without synostosis is considered not medically necessary. 

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• S1040 cranial molding orthosis, rigid, with soft interface material, custom fabricated, includes fitting and adjustments.
• A8000 Helmet, protective, soft, prefabricated, includes all components and accessories
• A8001 Helmet, protective, hard, prefabricated, includes all components and accessories
• A8002 Helmet, protective, soft, custom fabricated, includes all components and accessories
• A8003 Helmet, protective, hard, custom fabricated, includes all components and accessories
• A8004 Soft interface for helmet, replacement only

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Selected References: 

• Pollack IF, Losken HW, Fasick P. Diagnosis and management of posterior plagiocephaly. Pediatrics. 1997 Feb;99(2):180-5.
• Littlefield TR, Beals SP, Manwaring KH, et al. Treatment of craniofacial asymmetry with dynamic orthotic cranioplasty. Journal of Craniofacial Surgery 1998;9:11-17.
• Littlefield TR. Food and Drug Administration Regulation of Orthotic Cranioplasty. Cleft Palate-Craniofacial Journal, July 2001;38(4):337-340.
• Loveday BP, de Chalain TB. Active counter positioning or orthotic device to treat positional plagiocephaly? J Craniofac Surg. 2001 Jul;12(4):308-13. 
• Persing J, Swanson J, Kattwinkel J; American Academy of Pediatrics Committee on Practice and Ambulatory Medicine; Prevention and Management of Positional Skull Deformities in Infants Pediatrics 112 Number 1 July 2003.
• Teichgraeber JF, Seymour-Dempsey K, et al. Molding helmet therapy in the treatment of brachycephaly and plagiocephaly. J Craniofac Surg. 2004 Jan;15(1):118-23.
• ECRI. Cranial orthosis for the treatment of deformational plagiocephaly. Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service; November 2005, Issue No. 131. (Windows on medical technology; No. 131).
• Institute for Clinical Systems Improvement (available at www.ICSI.org) Cranial orthosis for deformational plagiocephaly. ICSI Technology Assessment Abstract #82;March 2004.
• de Ribaupierre S, Vernet O, et al. Posterior positional plagiocephaly treated with cranial remodeling orthosis.  Swiss Med Weekly. 2007 Jun 30; 137 (25-2): 368-72. 

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Policy History: 

Date                                        Reason                               Action

October 2011                         Annual review                     Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.