Medical Policy Revision: Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Effective January 21, 2020, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy, Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses.
Access our Medical Policy Manual to review this medical policy content.¹
Claims submitted for services provided on and after January 21, 2020 to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO) or Medicare Advantage (MA) plans will be processed as follows.
- Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by HCPCS code S1040 provided to patients between 3 and 18 months of age. Following our review of medical record information, these services may be denied as not medically necessary.
- Based on the submitted diagnosis code(s), the services represented by HCPCS code S1040 provided to patients between 3 and 18 months of age may be denied as not medically necessary.
- Regardless of the submitted diagnosis code(s), claims submitted for the services represented by HCPCS code S1040 to patients under 3 months of age or older than 18 months of age will be denied as not medically necessary.
Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after January 21, 2020.
¹ The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.