Cranial Remolding Orthosis (Cro) Device - Bluecross Blueshield Of Texas Page 2
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1
2Proceed to Part B
Part B – Cranial Index To Compare Width of the Head to its Length (measured in millimeters,
express as %)
Standard
Measurements
Calculation
Deviation %
Head width measurement from euryon (eu) on
Head width
one side of head to euryon (eu) on other side of
(eu to eu) x 100
= _______
head versus head length measurement from
Head length
=
glabella (g) point to opisthocranion (op)
(g to op)
Proceed to Part C
Part C – Head Circumference (measured in inches or centimeters, specify how expressed)
Increment
Date
Measurements
Percentile
Birth
3 months
6 months
9 months
12 months
Proceed to Part D
Part D – CRO Device Requested
Device Type and Name
Recommended Use
Treatment Time
(express in hours/day)
(express in
months)
Proceed to Part E if Request is for CRO Replacement ONLY
Part E – CRO Device Replacement
Explanation of Reason for Device Replacement (include documentation of head growth, comparison data
of current to pre-treatment measurements, and helmet/band adjustments made during treatment
course):
___________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________
Revised 07/2009
Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 2 of 2
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