Effective for dates of service on or after September 1, 2026, benefit criteria for cranial remolding orthosis (CRO) (procedure code S1040) will be updated in accordance with House Bill 426, 89th Legislature, Regular Session, 2025.
The updated benefit criteria specify that CRO may be a benefit when the client requires CRO as part of the treatment plan for a documented diagnosis of any of the following non-synostotic deformational plagiocephaly conditions:
- Lateral deformational plagiocephaly (LDP)
- Brachycephaly
- Asymmetrical brachycephaly
- Dolichocephaly
Definitions and Descriptions
CRO is defined by the Human Resources Code, Chapter 32, Subchapter B, Section 32.03126 as a custom-fitted or custom-fabricated medical device that is applied to the head to correct a deformity, improve function, or relieve symptoms of a structural cranial disease.
Plagiocephaly refers to an asymmetrical, flattened deformity of the skull and can be used to describe both synostotic and non-synostotic head symmetry.
Craniosynostosis occurs when there is a premature fusion of cranial sutures. Craniosynostosis may cause synostotic plagiocephaly, a flattened deformity of the skull as a result of the premature fusion of cranial sutures.
Non-synostotic deformational plagiocephaly (DP) is head-flattening that results from external forces that mold the skull in the first year of life. The following are categories of DP that may require treatment with a CRO:
- LDP is described as an asymmetric head which occurs when an infant’s skull is flattened on one side. This can be predominantly anterior (forehead flattening) or posterior (occipital flattening). The flattening may be accompanied by anterior displacement of the ear, forehead, and in severe cases, the orbit.
- Brachycephaly describes a short, wide head. The occiput flattens and there may be bilateral widening in the tempo-parietal regions. There may also be bulging noted above the ears.
- Asymmetric brachycephaly is the combination of plagiocephaly and brachycephaly. It is characterized by occipital flattening accompanied by parietal asymmetry. The flattening may be accompanied by anterior displacement of the ear, forehead, and in severe cases, the orbit.
- Dolichocephaly is characterized by flattening on both sides of the head and elongation from anterior to posterior.
Conservative therapy for treatment of non-synostotic plagiocephaly involves non-surgical, proactive methods to reshape the infant’s skull, primarily through consistent repositioning, increased tummy time, and physical therapy to treat underlying torticollis. These methods are most effective when started early (before 4–6 months of age) to alleviate pressure on the flat spot.
Claims Reimbursement
Claims for procedure code S1040 may be reimbursed for clients who are 3 months through 18 months of age and have been diagnosed with one of the following:
- Synostotic plagiocephaly as a result of craniosynostosis
- Non-synostotic plagiocephaly that meets diagnostic criteria
CRO will be limited to one device per lifetime, by any provider. This limitation may be exceeded with prior authorization.
Orthotist providers may be reimbursed for procedure code S1040 for services rendered in the home setting.
Prior Authorization and Documentation Requirements
CRO will require prior authorization and may be approved for the following diagnosis codes:
| Diagnosis Codes | |||||||
|---|---|---|---|---|---|---|---|
| Q040 | Q041 | Q042 | Q308 | Q672 | Q673 | Q674 | Q75001 |
| Q75002 | Q75009 | Q7501 | Q75021 | Q75022 | Q75029 | Q7503 | Q75041 |
| Q75042 | Q75049 | Q75051 | Q75052 | Q75058 | Q7508 | Q751 | Q752 |
| Q753 | Q754 | Q755 | Q758 | Q759 | Q781 | Q870 | |
Additional devices beyond the one-per-lifetime limitation may be considered for prior authorization with documentation of all the following:
- The initial device was obtained to treat either of the following:
- Synostotic plagiocephaly as a result of craniosynostosis
- Non-synostotic plagiocephaly, brachycephaly, asymmetric brachycephaly, or dolichocephaly
- Treatment with the device has been effective, but the client has not yet met the treatment goal.
- The new device is needed due to growth.
Documentation of medical necessity must be maintained in the client’s medical record.
If the client has craniosynostosis, a diagnosis of the type of craniosynostosis and synostotic plagiocephaly must be documented.
If the client has a diagnosis for non-synostotic plagiocephaly (e.g., LDP, brachycephaly, asymmetric brachycephaly, or dolichocephaly) one of the following criteria must be met:
- Cranial vault asymmetry (CVA) confirmed by a right or left discrepancy of greater than six millimeters in a craniofacial anthropometric measurement to include, but not limited to, the criteria set by the Children’s Healthcare of Atlanta Plagiocephaly Severity Scale
- Brachycephalic disproportion in the comparison of head length to head width that is confirmed by a cephalic index of two standard deviations of the mean
- Dolichocephalic disproportion in the comparison of head length to head width that is confirmed by a cephalic index of two standard deviations of the mean
If the client has a diagnosis of non-synostotic plagiocephaly (e.g., brachycephaly, asymmetric brachycephaly, or dolichocephaly), there must be documentation of at least two months of conservative therapy or physical or occupational therapy by a qualified health care professional that did not achieve a reduction of asymmetry or disproportion that would no longer meet the criteria listed above.
For more information, call the TMHP Contact Center at 800-925-9126.
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.