Advice on insurance claims, codes, and coverage for baby helmets
Insurance policies vary widely for orthotics use in general, and cranial molding helmets and bands are no exception.
Insurance coverage for helmet and band therapies varies widely based upon your family’s policy. Before you begin the actual helmeting process, examine your insurance policy closely. You will want to be aware of the ICD-9-CM diagnosis codes for your child’s condition as well as the HCPCS procedure codes relevant to your baby’s treatments. Ask your doctor’s office staff to provide you with this data – it can really come in handy if you need to file an appeal. Some of the codes most commonly used are listed here:
HCPCS Codes for baby helmets
- 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
- L0112 Cranial cervical orthotic, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated
- L0113 Cranial cervical orthotic, torticollis type, with or without join, with or without soft interface material, pre-fabricated, includes fitting and adjustment.
- S1040 Cranial remolding orthotic, rigid with soft interface material, custom fabricated, includes fitting and adjustments
ICD-9-CM Diagnosis Codes for baby helmets
- 723.5 Torticollis, unspecified; Contracture of Neck
- 738.19 Other Acquired Deformity of Head
- 738.2 Acquired Deformity of Neck
- 744.89 Other specified anomalies of face and neck
- 754.0 Certain congenital musculoskeletal deformities of skull, face, and jaw; Plagiocephaly
- 754.1 Certain congenital musculoskeletal anomalies of sternocleidomastoid muscle; Contracture
- 756.0 Other congenital musculoskeletal anomalies of skull and face bones; Craniosynostosis
- 765.00 – 765.19 Extreme Immaturity and Other Preterm Infants
- 767.3 Birth Trauma, Other Injuries to Skeleton, i.e. Skull
- V48.6 Disfigurements of head
Make sure that your insurance company covers the codes that are relevant to your child’s particular case. If not, see if they cover a different code for the same condition, and if your doctor’s office can use that code instead. Also, make sure that the codes your doctor’s office is filing are current – outdated codes are generally denied. Once you have the relevant code information, contact your insurer for pre-authorization if your policy requires it. Keep your insurance information for your child’s condition neatly organized and in its own folder. Obtain any referrals necessary, and make sure that you submit all paperwork as quickly as possible. Appeals processes can take a long time, and the best way to avoid them is making sure that everything is in order before you get your child’s orthotic.
Every case is different, so be patient and know that you are doing what you can to help your child. For more information on dealing with insurance claims, please see this article.