1. Aetna considers cranial remodeling bands (or helmets) as medically necessary orthoses for treatment of moderate to severe positional head deformities associated with premature birth, restrictive intrauterine positioning, cervical abnormalities, birth trauma, torticollis (shortening of the sternocleidomastoid muscle) and sleeping positions in children when banding is initiated at 4 to 12 months of age and the following conditions are met:

   1. A 2-month trial of conservative therapy consisting of repositioning the child's head such that the child lies opposite to the preferred position, has failed to improve the deformity and is judged to be unlikely to do so, and

   2. One of the following must be met:

      1. Anthropometric data (measurements used to evaluate abnormal head shape by measuring the distance in mm from one pre-designated point on the face or skull to another, comparing the right and left sides) verifies that a moderate to severe plagiocephaly is documented by a physician experienced in such measurement. (Note: These measurements are generally obtained by the orthotist fitting the band or helmet.) The most significant measurements used in this initial evaluation are skull base asymmetry, cranial vault asymmetry, orbitotragial depth, and cephalic index.

         DIAGRAM:

         

         A difference of asymmetry greater than 6 mm between anthropometric measurements (see diagram above) in any of the anthropometric data in the first column of the following table warrants coverage of a trial of orthotic banding to correct the craniofacial deformity:

         Anthropometric Data	Measurement	Measures
         Cranial base (sn-t on same side)	from right and left subnasal point (sn) to tragus (t)	measures maxillary depth or right and left morphological face height
         Cranial vault (fz R-euL, fz L-euR)	from frontozygomaticus point (fz) on one side of face to euryon (eu)	measures cranial vault asymmetry
         Orbitotragial depth (ex-t, R, L)	from exocanthion point (ex) to tragus (t)	measures orbito-tragion depth (exocanthion)

      2. For brachycephaly evaluation, a cephalic index 2 standard deviations below mean (head narrow for its length) or 2 standard deviations above mean (head wide for its length) warrants coverage of a trial of orthotic banding to correct the craniofacial deformity in a child after 4 months of age and before 12 months of age. (Note: These measurements are generally obtained by the orthotist fitting the band or helmet.)

         Head width (eu - eu)	from euryon (eu) on one side of head to euryon (eu) on the other side	measures greatest transverse diameter or maximal head width
         Head length (g-op)	from glabella point (g) to opisthocranion (op)	measures maximal head depth or length

         Cephalic index = Head width (eu - eu) x 100 
                                       Head length (g - op) 

         Sex	Age	-2SD	-1SD	Mean	+1SD	+2SD
         Male	16 days to 6 months	63.7	68.7	73.7	78.7	83.7
         	6 - 12 months	64.8	71.4	78.0	84.6	91.2
         Female	16 days to 6 months	63.9	68.6	73.3	78.0	82.7
         	6-12 months	69.5	74.0	78.5	83.0	87.5

      3. Infants who develop significant plagiocephaly secondary to a constant head position required for long-term hyperalimentation who do not respond to simple changing of the catheter location allowing the head to be repositioned.
      4. Members with excess frontal bossing secondary to sagittal synostosis
      5. Members with moderate to severe residual plagiocephaly after surgical correction.
      6. Premature infants with dolichocephalic head shape who have developed a misshapen head secondary to sustained head position.
         

      A second cranial remodeling band or helmet is considered medically necessary for children who meet the afore-mentioned criteria if the asymmetry has not resolved after 2 to 4 months.

2. Aetna considers the use of a cranial remodeling band (or helmet) cosmetic for persons not meeting the afore-mentioned criteria. 

3. Aetna considers use of a cranial remodeling band (or helmet) medically necessary for infants with synostotic plagiocephaly to correct continued asymmetry following surgery when criteria in section I.B above are met (i.e., a trial of conservative therapy is not needed when the cranial remodeling band is used following surgery for synostotic plagiocephaly). Aetna considers the use of a cranial remodeling band (or helmet) without surgery to correct asymmetry in infants with synostotic plagiocephaly as cosmetic.

Plagiocephaly (an asymmetrical head shape) is most often the result of an infant spending extended periods of time on their back, typically during sleep. Plagiocephaly can also occur as a feature of other disorders (e.g., craniofacial disorders, torticollis, cervical anomalies) and is categorized as either positional or synostotic (premature union of cranial sutures). Although 1 in 300 infants exhibit variable degrees of plagiocephaly, true sutural synostosis, which interferes with cranium development and may cause increased intracranial pressure, occurs in only 0.4 to 1 per 1000 live births.

Positional plagiocephaly is treated conservatively and many cases do not require any treatment as the condition may resolve spontaneously when the infant begins to sit up. When the deformity is moderate or severe and a trial of repositioning the infant has failed, a pediatric neurologist, neurosurgeon or other appropriate specialist in craniofacial deformities may prescribe a cranial remodeling band to remodel the misshapen head. The custom molded orthotic is designed to fit a child’s head for two to four months.

Examples of brands of cranial remodeling bands and helmets include the DOC BAND®, Gillette Children's Craniocap, and the STARband™ Cranial Headband. Average treatment time with the cranial remodeling band or helmet is four and a half months.

A systematic evidence review of cranial orthosis treatment for infant deformational plagiocephaly prepared for the UK National Health Services (NHS QIS, 2007) found no randomized controlled trials assessing the effectiveness of cranial orthoses for the treatment of deformational plagiocephaly were identified. The assessment stated that no evidence-based conclusions can be reached on the effectiveness of cranial orthoses due to the limited methodological quality of the available trials. "Further research in the form of a randomised controlled trial is needed to determine the true effectiveness of cranial orthoses."

While infants with positional plagiocephaly may be treated with head positioning and/or helmeting, the standard treatment for synostotic plagiocephaly (asymmetrical head caused by premature closure of the cranial sutures) is surgery. There is some evidence suggesting that a cranial remodeling band (or helmet) may improve outcomes following surgery to treat synostotic plagiocephaly. Seymour-Dempsey, et al. (2002) retrospectively reviewed the results of surgery alone (n = 6) versus surgery and postoperative banding (n = 15) in treating children diagnosed with sagittal synostosis. The investigators reported that correction toward a normal cephalic index was seen in the banded group throughout the course of treatment, while this trend was not present in the non-banded group.