Cranial Remolding Orthosis (Cro) Device - Bluecross Blueshield Of Texas
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Cranial Remolding Orthosis (CRO) Device
Cranial Remolding Orthosis (CRO) Device
Medical Policy - DME103.007
Please complete all appropriate questions fully.
Suggested medical record documentation:
•
Current History & Physical
*Failure to include suggested medical record documentation may result in delay or possible
denial of request.
Note: For Predetermination, please fully complete and submit the
Predetermination Request
Form.
PATIENT INFORMATION
Name:
Member ID
Group ID
PROCEDURE INFORMATION
Request for CRO:
Please complete all the questions fully. Failure to do so will result in
delay or possible denial of claims.
Patient Age ______
Male ______
Female ______ Multiple Birth?
Yes ____ No _____
Primary Diagnosis __________________________________ Date _________________
Secondary Diagnosis ________________________________ Date _________________
Contributing Factor(s) resulting in diagnosis _____________________________________
Conservative Therapy done?
Yes _________
No __________
If Yes, type of Conservative Therapy ___________________________________
_________________________________________________________________
___________________________________________________ # of Months ______
Measurement Completed by Physician or Orthotist?
Yes _______
No __________
If Yes, done manually?
Yes _______ No __________
If Yes, done by computer modeling scanner?
Yes _______
No __________
If Yes, graph/grid included with CRO request?
Yes _______ No __________
Photographic Evidence included with CRO request?
Yes _______
No __________
Surgery Required?
Yes _________ No __________
If Yes, specify the procedure:
________________________________________
Part A - Craniofacial Anthropometric Measurements to Define Asymmetry (measured in
millimeters)
Area
Measurements
Calculation
Discrepancy
from right and left subnasal (sn) point
sn to left t = ________
Cranial (skull)
(midline under the nose) to tragus (t) (the
minus
Base
cartilaginous projection in front of the
sn to right t = ________
external auditory canal)
left fz to right eu =
from right and left frontozygomaticus (fz)
________
point (forehead just above the eye orbit)
Cranial Vault
minus
to right and left euryon (eu) (most lateral
right fz to left eu =
point of the head)
________
left ex to left t =
Orbitotragial
from right and left exocanthion (ex) point
________
Depth or
(outer point of the eye where the eyelids
minus
Distance
meet) to tragus (t)
right ex to right t =
_______
Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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