Update to Cranial Remolding Orthosis Benefit Criteria Effective September 1, 2026

By August 15, 2026: Billing team must implement the following changes for all S1040 claims with service dates on or after September 1, 2026: (1) Update billing system to require prior authorization for procedure code S1040 for patients aged 3-18 months with any diagnosis code Q040-Q870 listed; (2) Configure system to enforce one device per lifetime limitation with override capability requiring prior authorization; (3) Create or update claim submission checklist to verify documentation includes: (a) if craniosynostosis: type of craniosynostosis and synostotic plagiocephaly diagnosis; (b) if non-synostotic plagiocephaly: cranial vault asymmetry >6mm OR cephalic index ±2 standard deviations AND documentation of at least 2 months of conservative therapy or physical/occupational therapy that failed to reduce asymmetry; (4) Update prior authorization request form to require these specific measurements and therapy documentation; (5) Train billing and credentialing staff on new diagnostic criteria (LDP, brachycephaly, asymmetric brachycephaly, dolichocephaly); (6) Notify orthotist providers that home setting services for S1040 are now reimbursable. Claims submitted without prior authorization or required documentation will be denied. Coordinate with individual MCOs as administrative procedures may vary from traditional Medicaid.