Cranial helmets are considered "Durable Medical Equipment " and can absolutely be covered by insurance! Your insurance company typically wants to make sure that a helmet is medically necessary before they will cover the device. This use to mean your child only needed a prescription from the pediatrician and then their device would be covered. These days however, insurance companies want more information than ever to make sure medical devices are not being needlessly prescribed. It is important to prove medical necessity, AND THAT'S where the experts come in.
We agree that cranial remolding helmets are medically necessary and advocate their use. Our staff has worked over the years to establish parameters for medical necessity with our local medicaid and private insurance companies. These parameters are based on the most current research and allow us all to speak the same language about baby heads. We start with a free consultation to determine medical necessity and request a prescription/referral. These are the first steps in getting your helmet covered by insurance.
Patients are sometimes sent to us by their pediatrician, therapist, or a neurosurgeon. Some families choose to make an appointment for an evaluation before they are referred. A prescription or referral is not needed to come see us and our consultations are always free. (In fact all of our appointments are always free! We only charge for the helmet).
At this initial consult we will take measurements and determine if your child has deformational plagiocephaly. We discuss their medical history and any repositioning attempts you have made. We determine if they need to start helmet therapy and then request a prescription from your pediatrician if we don't have one already. Some of our local pediatricians rely on our scans to help determine if it's time to treat and send the prescription after the initial evaluation.
What to Know About Medical Necessity
Opinions don't determine medical necessity, numbers do! So ask the experts and schedule an eval.
Your insurance typically has specific parameters for what they determine to be medically necessary and if they don't we will send them information to help them create parameters
If your child meets criteria and helmets are a covered benefit we will help you get your helmet covered even if it is initially denied for not being medically necessary. We will help call insurance and appeal if necessary. We are experts at advocating and explaining! Note that if your helmet is not a covered benefit, that is a different matter. Keep scrolling for more info on this!
In some cases, even though your baby's helmet is medically necessary, your insurance may want proof that you have been repositioning your baby off the flat side of their head. They may even want proof that your pediatrician told you how to do repositioning, but each insurance is different. We can help you with how to provide proof of this.
At times insurance will want a history of measurements. Our office is able to provide scans as evidence that your child's head is not improving on its own. We offer these scans for free, no risks to baby and can do them at just a few weeks of age if there are concerns.
What Does Covered Mean?
Poof! My helmet is covered by insurance! That means I don't owe anything right?
Answer: Maybe right! Maybe wrong.
If your helmet is covered by insurance it is still subject to your plan's benefits. This means you may have to pay towards your deductible or you may have a copay for the helmet. It also could mean it is 100% covered and you don't owe anything. The process varies for each insurance company and then even still varies for each specific plan. That is why it is important to have us check your benefits even if you have already heard from a friend or co-worker what their insurance may have covered. We know the codes and verbiage so that you can get the bottom line information the first time.
What you should know is that once the helmet is covered and you are given your financial responsibility, you are not charged for anything else. It is not our policy to charge a copay for visits because we want your babies to be seen when they need to be seen.
When Insurance Does Not Cover The Helmet
Being denied for medical necessity it one thing, but if your insurance "does not cover a helmet" there is typically nothing we can do to get it approved. If insurance does not cover the helmet it is usually stated by your benefits coordinator that "helmets or cranial orthotics are not a covered benefit".
In the past, with specific plans, we will work with families on advocating for cranial helmet coverage. Typically, if an employer does not have cranial orthotics on the plan we are able to provide proof of medical necessity and in some instances, over time, we have gotten the employer to change the policy.
If you have a private healthcare plan that denies coverage of a helmet, you may be eligible for a grant that assists in the coverage of durable medical equipment. Additionally, we accept Care Credit and financing options are available.
When to Appeal
Have I mentioned that we will appeal anything we can? Because we can and will get it approved if it is a covered benefit and medically necessary.
If insurance does not cover the helmet because your baby's head shape is considered cosmetic (not medically necessary), we are typically able to send pictures and write up specifically how we are wanting to change the head. There are new measurements that consider the volume of the head and facial shifting that we can use to address concerns with head "height" that was previously considered cosmetic. Sometimes we are able to get these cases approved with our latest technology and research.
If the helmet is denied for the baby being too old, we can appeal if the baby was born prematurely or has confirmed open soft spots .
If the helmet was denied because the baby wasn't in therapy long enough or not at all, we can address these points on a case by case basis.
We are highly experienced at talking with medical reviewers about the benefits and necessity of cranial remolding orthotics. Unless your insurance states "it is not a covered benefit", it is possible to appeal to get it covered.
When a helmet is not going to be covered by insurance we then have to enter a cash price scenario. This is the case for babies that do not have helmets as a covered benefit or do not have insurance. We do not believe in pricing over the phone because this is a custom medical device for your baby's head and each baby has individual needs. Our cash pricing can be less than what insurance will pay for a helmet and how we price your care depends on:
Severity of your baby's head shape
Age of your baby
Current head percentile on the growth chart
Materials needed for the helmet (sensitive skin, cheek piece, special design)
Because we have one helmet guarantee and don't charge for visits, we want to be sure we are giving an accurate financial responsibility quote. What's more important, we want to make sure you are at the right place. If there are underlying concerns, we can help, but only if we get a good idea of what's going on and conduct that initial consult in person.
Take Away Information
Our office can be the first and last stop when starting your quest for cranial coverage. We offer free and experienced insight to help you understand:
If your little one needs a helmet
What your insurance covers
How to get it covered as medically necessary
It can sometimes be a long journey with us and other times it can be approved in a day. We offer cash pricing in case that your insurance does not have helmets as a covered benefits. If your little one has underlying cranial or developmental concerns we can also help you with the conversation with your pediatrician to get where you need to go. Bottom line: it costs nothing to get the information, so don't let financial worries delay treatment.