Number:DME103.007 Effective Date:03-01-2020 Coverage: *CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT* Use of an adjustable cranial orthosis may be considered medically necessary following cranial vault remodeling surgery for synostosis. Use of an adjustable cranial orthosis for synostosis in the absence of cranial vault remodeling surgery is considered not medically necessary. Use of an adjustable cranial orthosis as a treatment of persistent plagiocephaly or brachycephaly without synostosis may be considered medically necessary when all of the following conditions have been met: • The patient is between 3 and 18 months old; • Documented failure of conservative therapy (repositioning and/or physical therapy) of at least 2 months duration; and • Either one of the following sets of measurements or indications: 1. Asymmetrical appearance confirmed by a right/left discrepancy of greater than 6 mm in any craniofacial anthropometric measurement; or 2. Brachycephalic or dolichocephalic disproportion (comparison of head length versus head width) confirmed by a cephalic index of 2 standard deviations above mean or 2 standard deviations below mean. Use of an adjustable cranial orthosis is considered not medically necessary for all other indications not outlined above. NOTE 1: Measurements are usually obtained by the physician or orthotist fitting the helmet or headband. EXCEPTION: TEXAS CHIP and Medicaid (STAR) contracts only: The following directives are required when reviewing patients under the Texas Children’s Health Insurance Program (CHIP) or Medicaid State of Texas Access Reform (STAR) Program: • CHIP – Cranial remolding orthotics are a non-covered service or benefit. • Medicaid STAR – Per Texas Medicaid Bulletin Number 240, March/April 2012, page 14, “Cranial remolding orthosis…, is no longer a benefit for the treatment of positional plagiocephaly as position plagiocephaly is considered cosmetic. Cranial remolding orthosis is allowed for synostotic plagiocephaly.