Cranial Remodeling (CPB 0379, reviewed 2026-05-26)

REQUIREMENTS - By June 26, 2026: (1) Billing team must update claims processing system to require Standard Written Order (SWO) documentation before accepting cranial remodeling band/helmet claims; implement system block to deny claims submitted without completed SWO. (2) Providers must be educated that all cranial remodeling prescriptions must include: member identification, order date, HCPCS code with description, treating practitioner name/NPI/signature, and complete list of separately billed options/accessories. (3) Clinical staff must verify that patient medical records contain: documented failed 2-month conservative repositioning therapy trial, anthropometric measurements (cephalic index, CHOA level, CVA, CVAI, OTDA, SBA, or TDD) showing >6mm asymmetry or cephalic index 2 SDs from mean, patient age 3-12 months at initiation, and physician notes from treating practitioner (MD/DO/PA/NP/CNS only—NOT orthotists or supplier statements). (4) Update intake forms and EMR templates to require documentation of conservative therapy failure and specific measurement values. (5) Establish audit process to flag claims for patients >12 months old or without documented failed conservative trial, as these will be denied as cosmetic/not medically necessary. (6) Train billing staff that records from suppliers with financial interest in claim outcome cannot serve as sole documentation—medical records from treating practitioner required. CONSEQUENCES: Claims submitted without completed SWO will be denied as not medically necessary per DME MAC policy. Claims lacking documented failed conservative therapy or required anthropometric measurements will be denied. Second orthosis claims must show asymmetry has not resolved after 2-4 months or patient is <8 months with inadequate head control.