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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.7 Orthotic and Prosthetic Services (CCP) : 2.7.3 Cranial Molding Orthosis : Prior Authorization and Documentation Requirements
Cranial molding orthosis 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 orthosis 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 orthosis, 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 orthosis will be considered for prior authorization for use after surgery for cranial deformities, including craniosynostosis. Cranial molding orthosis 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 orthosis must be prior authorized for reimbursement through CCP with documentation supporting medical necessity. Written documentation must include:
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.
Requests for clients with a comorbid diagnosis that prohibits repositioning will be evaluated on an individual basis.
When requesting a subsequent cranial molding orthosis, the provider must include documentation of medical necessity including new anthropometric measurements.
Prior authorization is denied when pricing is not included with the CCP Prior Authorization Form.

Texas Medicaid & Healthcare Partnership
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