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Coverage criteria policies

Cranial remolding helmet/band and protective helmet – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for a Cranial Remolding Helmet/Band or a Protective Helmet when request is for a covered indication (see below).

Coverage

A Cranial Remolding Helmet/Band or a Protective Helmet is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Cranial Remolding Orthotics

Code: S1040
A cranial remolding orthotic is considered medically necessary for treatment of head deformities associated with:

  • Premature birth
  • Restrictive intrauterine positioning
  • Torticollis
  • “Back to Sleep” sleeping positions
Protective Helmet

Codes: A8000, A8001, A8002, A8003

Covered for recipients at risk of head injury due to medical condition such as seizures or developmental disability.

Indications that are not covered

Cranial Remolding Helmet/Band or a Protective Helmet is not covered for any additional indication, including, but not limited to:

  • Repair costs for a prosthetic or orthotic device that is under warranty
  • Orthotics that are to be used only during sports or other leisure activities

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

    Codes

    Description

    S1040

    Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

    A8000

    Helmet, protective, soft, prefabricated, includes all components and accessories

    A8001

    Helmet, protective, hard, prefabricated, includes all components and accessories

    A8002

    Helmet, protective, soft, custom fabricated, includes all components and accessories

    A8003

    Helmet, protective, hard, custom fabricated, includes all components and accessories

    A8004

    Soft interface for helmet, replacement only

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual: Equipment and Supplies: Orthotics. Revised 09/13/2012.
  2. Minnesota Health Care Programs (MHCP) Provider Manual: Medical Supply Coverage Guide. Revised 04/26/2017.

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Policy activity

  • 02/10/2016 - Date of origin
  • 02/01/2017 - Effective date
Review date
  • 02/2017
Revision date
  • 08/15/2016

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