Adjustable Banding as a Treatment of Plagiocephaly Printer-Friendly Version   

Medical Policy: 01.01.05 
Original Effective Date: August 2000 
Reviewed: January 2009 
Revised: August 2007 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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.

Policy: 

• As a nonsurgical treatment of plagiocephaly or brachycephaly without synostosis, adjustable banding is considered cosmetic.
• As an adjunctive postsurgical therapy for synostotic plagiocephaly, adjustable banding is considered investigational.

Rationale:

This policy is based on a 1999 TEC Assessment along with an annual search of the peer reviewed scientific literature.  The 1999 TEC assessment  offered the following observations and conclusions:

• The health outcomes of untreated plagiocephaly without synostosis (PWS) are uncertain. There are no published data on the effects of PWS on neuropsychological deficits, developmental delay, temporomandibular joint disorders, or psychosocial concerns related to a perceived abnormal appearance. The major reason for intervention is to optimize the cranial contour to achieve an acceptable appearance, not to prevent or correct adverse developmental consequences.
• The natural history of PWS is not well documented. Remarkably few adults have deformities of cranial symmetry or shape, suggesting that the abnormality is either self-correcting or effectively masked by a combination of increased cranial circumference and hair growth.
• There are no randomized studies that directly compared treatment modalities for PWS. The available studies were either nonrandomized weakly controlled comparisons or uncontrolled case series. Because little information exists about the true risk of leaving PWS untreated, it is difficult to compare treatment techniques, since a treatment effect cannot be reliably differentiated from spontaneous recovery. The available data do not clearly support one treatment technique as superior to another or as superior to no treatment. Moreover, the degree of cranial asymmetry that constitutes an abnormality warranting intervention versus normal human variation cannot be determined from the available data.
• Because of the above factors, the TEC Assessment concluded that the evidence regarding dynamic orthotic cranioplasty as a treatment of PWS is insufficient to permit conclusions.

There are also inadequate data to permit conclusions regarding the use of dynamic orthotic cranioplasty as an adjunct after surgery for synostotic plagiocephaly. 

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Procedure Codes and Billing Guidelines: 

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

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Selected References: 

• The Medical Policy Reference Manual (MPRM) developed by the Blue Cross and Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
• 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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Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2009 American Medical Association. All Rights Reserved.

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.