If your baby has been diagnosed with a type of plagiocephaly, brachycephaly, scaphocephaly or torticollis you may have difficulty getting your insurance company to pay. You and your doctor would never consider this therapy cosmetic. Yet the long-term effects of these conditions are not well understood. Although there are insurance companies that will provide full insurance coverage, others treat cranial helmets and bands as cosmetic devices exclusively, with the patient ultimately footing the bill. It would be prudent for you, the parent, to know the final costs that will be incurred before beginning this therapy, if possible. Does medicaid cover plagiocephaly helmet? Does my insurance pay for 50%? These are some good questions to ask prior to helmet therapy. However, research has shown, that the treatment window of this therapy is not that long. We will explore the different payment options in this article beginning with insurance. Other options are Care Credit, government grants, GoFundMe, publicity on television or internet and even private charity funding.

Insurance Coverage

One of the first things you must do is make sure that you and your cranial therapy provider use the correct insurance codes. Billing codes make a large difference in the way an insurance company addresses a claim. HCPCS and ICD-9-CM are diagnosis codes to be aware of. Other examples of codes are, DME (durable medical equipment), and S1040. Be aware that there is a code, L0100 that is for a protective helmet not a cranial remodeling helmet. Cranial helmets fall into the insurance of orthotics and prosthetics, which are usually in the category of DME in the majority of insurance plans. The doctor must write a specific diagnosis which includes the words, “a cranial orthosis is medically necessary.” The diagnosis letter may also state whether the syndrome was present at birth and explain specifically the consequences that might occur if the problem is not addressed immediately.

There is a specific protocol that your infant must meet prior to the insurance company agreeing to reimbursement for a cranial helmet. The majority of insurance companies today consider the helmets as medically warranted. The following criteria must be met before your insurance company will agree to payment.

1. Conservative therapy with a specifically trained cranial physical therapist for a two-month trial period. This therapy will consist of re-positioning the baby’s head so that the baby lies the opposite way than the baby prefers. This therapy has to be called unsuccessful after the two-month period to qualify for a helmet.

2. Accurate measurement of the head verifying severe plagiocephaly (or whatever the specific problem is.) The most common measurements are the skull base asymmetry, cranial vault asymmetry (CVA -the measurement of the top of the head), orbitotragial depth (the measurement from the corner of the eye to the tab of the ear), and cephalic index ( width and length of the head) . Different insurance companies have different measurement requirements. (see images below)

Grant Providing Organizations

If the insurance option fails, grants are another major funding source. It is not that difficult to file a grant proposal. Grant providers will ask for all the paperwork (make sure you always make copies) and medical records of your baby’s case. The paperwork includes, the insurance documents and denials, diagnosis, previous therapy treatments and estimates of the cost of the helmet or band or your choice. They may also ask about your baby’s story and why he or she deserves a helmet. Military families may have special grants through their local military relief organizations.

Media Involvement

In July, 2018, a television station helped a mother, Heather Brooks of Monroe, North Carolina get the corrective helmet her baby needed. Three months after her baby, Arcturus, was denied the $4,000 cranial helmet coverage by their insurance provider, Mrs. Brooks contacted the television station, Fox 46 for their help. Baby Arcturus was born with plagiocephaly and was denied coverage for the helmet by her insurance company. Fox 46 was able to successfully find a company willing to donate the helmet to the Brooks’ for free. Mrs. Brooks is presently suing her insurance company for denial of the coverage. Fox 46 ascertained that there were other families in the same predicament of insurance coverage denials for cranial therapy helmets. Blue Cross Blue Shield settled a class action claim in 2008 after they were accused of refusing to pay for literally hundreds of baby cranial helmets.

Mrs. Brooks is expecting her second child presently. She is attempting to make sure that her present insurance company will pay in case her expected baby has the same problem. Her husband’s insurance company, United Healthcare, stated that the helmet was excluded from coverage under their plan. Fox 46 contacted United Healthcare and this was their response.

“We pay for all services that are covered benefits, but cranial bands are expressly not included in the Brooks family plan”. Unless Mr. Brooks’ employer changes their insurance plan or he changes jobs the Brooks family is stuck in the same place. They are praying for a healthy baby.

On a side note, interestingly, although United Healthcare is not the best insurance company for cranial therapy helmets they have a good grant program. Families who quality can receive up to $5,000 under this grant program called Grants for Helmets.

Charity Foundations

If your family is in dire straits and cannot afford to pay for your baby’s helmet, there are several charity foundations that can help.

Care Credit provides health care loans at low interest for needy families.

Share A Smile provides great discounts for craniofacial treatments.

GoFundMe is the most popular option which is based on crowdfunding. Families can set up a donation web page and receive donations from family and friends. There are other websites as well like Charidy.

Hopefully you will not have to use the list of options we have set out. As cranial therapy becomes more accepted with doctors and therapists as advocates, insurance companies will be more agreeable to paying for baby’s helmets. Cranial helmet therapy has become a proven successful therapy for plagiocephaly and torticollis. Fortunate children who use this therapy grow up to lead beautiful and productive lives. The results of this therapy will be proof to the insurance companies. They will realize that the high costs of operations later in life for those unfortunate individuals who could not afford the helmets when they were infants, will not be a viable alternative. Please use every means at your disposal to fight for your child. Parents should discuss payment and discount plans with the Orthotist if need be.