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2.7.3.2 Prior Authorization and Documentation Requirements
Cranial molding orthotics may only be considered for prior authorization when they are part of a treatment plan for shaping the skull in cases of post-operative plagiocephaly with synostosis or positional plagiocephaly with an associated functional impairment. Documentation must be kept showing that the use of the cranial molding orthotic will modify or prevent the development of such impairment, including orofacial and musculoskeletal disorder.
Cranial molding orthotics when used as a treatment of plagiocephaly without synostosis is considered cosmetic, not medically necessary, and therefore not a benefit of Texas Medicaid.
The definition for cosmetic, as it applies to cranial molding orthotics, includes surgery or other services used primarily to improve appearance and not to restore or correct significant deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic process.
Requests for cranial molding orthotics will be considered for prior authorization for use after surgery for cranial deformities, including craniosynostosis. Cranial molding orthotics may be considered as a benefit of the Medicaid Program when included as part of a treatment plan to reshape a skull deformity due to pathologic processes.
Cranial molding orthotics must be prior authorized for reimbursement through CCP with documentation supporting medical necessity. Written documentation must include:
• The assessment and recommendations of the appropriate primary care physician, pediatric sub-specialist, craniofacial team, or pediatric neurosurgeon.
•A full description of the physical findings, precise diagnosis, age of onset, and the etiology of the deformity.
•Reports of any radiological procedures used in making the diagnosis.
•Documentation that the client is at least 3 months of age but not greater than 18 months of age.
•Anthropometric measurements documenting greater than 10 mm of cranial asymmetry.
•For clients who are 5 months of age and younger, documentation of aggressive repositioning, with or without physical therapy, of at least three months' duration without improvement in cranial asymmetry.
Note: Due to the mobility of children who are 6 months of age and older and the limited timeframe during which the device may be effective, repositioning is not indicated in this age group.
•Plan of treatment and or follow-up schedule
Prior authorization is denied when pricing is not included with the CCP Prior Authorization Form.
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