Collection: MUSE MEDICAL

Historically, health insurers have viewed wigs as cosmetic items, excluding them from medical necessity coverage. To overcome this hurdle, it's essential to adopt the terminology used by insurers.

When communicating with your healthcare provider or insurance company, it's crucial to use the term "cranial prosthesis" instead of "wig." This distinction acknowledges the medical purpose of the wig, increasing the likelihood of insurance coverage.

By using the correct terminology, you can effectively navigate the insurance process and advocate for the coverage you need.

Prior to purchasing a Cranial Prosthesis, it is essential to confirm your insurance coverage. Contact your insurer directly and disclose your medical diagnosis that lead to your chronic hair loss.

Many insurance policies do not explicitly list cranial prosthesis coverage in their literature or online. Therefore, a phone call is necessary to determine your policy's specifics.

If your insurance is provided through your employer, consider consulting with your Human Resources Benefits Manager for additional guidance.

When inquiring about your coverage, ask the following questions:

1. Is a cranial prosthesis covered under my policy?
2. How many cranial prostheses am I eligible for reimbursement per year?
3. What is the maximum reimbursement amount for each cranial prosthesis?
4. Are there specific requirements for reimbursement, such as customization or a medical-grade cap?
5. Are there preferred retailers or "in-network" providers for purchasing a cranial prosthesis?
6. What is the step-by-step process for submitting a claim for reimbursement?

To qualify for reimbursement for a cranial prosthesis, you will need to obtain documentation from your healthcare professional.

Schedule a consultation with your dermatologist or specialist to confirm your medical diagnosis that lead to your chronic hair loss.

Your healthcare provider will need to provide a letter or prescription that includes the following essential details:

• Diagnosis Confirmation: A statement confirming your diagnosis that lead to your chronic hair loss.
• Treatment Recommendation: A specification that a cranial prosthesis is the recommended treatment.
• Diagnosis Code: It's essential to consult with your healthcare professional to determine the most accurate and specific codes for individual cases.

The relevant ICD code:
Alopecia Areata
- L63.0: Alopecia totalis (complete hair loss on the scalp)¹
- L63.1: Alopecia universalis (complete hair loss on the body)¹
- L63.2: Ophiasis (hair loss in a crescent shape)¹
- L63.8: Other alopecia areata¹
- L63.9: Alopecia areata, unspecified¹

Androgenic Alopecia
- L64.0: Drug-induced androgenic alopecia¹
- L64.8: Other androgenic alopecia¹
- L64.9: Androgenic alopecia, unspecified¹

Other Nonscarring Hair Loss
- L65.0: Telogen effluvium¹
- L65.1: Anagen effluvium¹
- L65.2: Alopecia mucinosa¹
- L65.8: Other specified nonscarring hair loss¹
- L65.9: Nonscarring hair loss, unspecified¹

Cicatricial (Scarring) Alopecia
- L66.0: Pseudopelade¹
- L66.1: Lichen planopilaris¹
- L66.2: Folliculitis decalvans¹
- L66.3: Perifolliculitis capitis abscedens¹
- L66.4: Folliculitis ulerythematosa reticulata¹
- L66.8: Other cicatricial alopecia¹
- L66.9: Cicatricial alopecia, unspecified¹

New Codes for Specific Hair Loss Conditions
- L66.81: Central centrifugal cicatricial alopecia (CCCA)¹
- L66.12: Frontal fibrosing alopecia (FFA)¹

Cancer patients experiencing hair loss due to their condition or treatment can use the following ICD-10 codes to classify their condition and potentially receive coverage for a cranial prosthesis wig:

- L65.1: Anagen effluvium, which is a common condition causing hair loss in cancer patients undergoing chemotherapy or radiation therapy¹.
- L65.0: Telogen effluvium, another condition that may cause hair loss in cancer patients due to stress, chemotherapy, or radiation therapy¹.
- L64.0: Drug-induced androgenic alopecia, which may be applicable if the hair loss is caused by medications used to treat cancer¹.

Additionally, cancer patients may also use codes related to their specific type of cancer, such as:

- C00-C96.9: Malignant neoplasm of various sites¹.

¹ source: www.icdlist.com

It's essential to consult with a healthcare professional to determine the most accurate and specific codes for individual cases.

• NPI Code: Your healthcare provider's unique National Provider Identifier (NPI) code.
• Physician's Signature: Your healthcare provider's signature, authenticating the documentation.
• Additional Requirements: Any specific information your insurance company requires.
  
  Ensure that your healthcare provider includes all required details to facilitate a smooth reimbursement process.

Prior to purchasing your Cranial Prosthesis, confirm with your retailer that they can provide a medical invoice, a necessary document for your insurance claim.

The Cranial Prosthesis receipt or invoice from the retailer should include the following essential details:

1. Product Description: The item purchased should be listed as a "Cranial Prosthesis," not a "wig."
2. Pricing Information: The invoice should include the price of the cranial prosthesis and any additional customization fees.
3. Retailer's Tax ID Number: This is a required piece of information.
4. HCPCS Code: As of October 2024, the HCPCS code for cranial prosthesis is A0282.
5. NPI Code: If applicable, the retailer's National Provider Identifier (NPI) code.
   
   When selecting a Cranial Prosthesis, consider the potential impact of the wig type on reimbursement. Some insurers may prefer medical-grade wigs specifically designed for individuals with medical hair loss. Clarify this with your insurer during your initial inquiry about your coverage.

To ensure a smooth claims process, gather and prepare the necessary documents:

1. Diagnosis Letter: Obtain a letter or prescription from your healthcare provider, confirming your diagnosis and the need for a cranial prosthesis.
2. Receipts and Invoices: Collect all receipts and invoices related to your wig purchase.
3. Insurance Claim Form: Obtain and complete the claim form from your insurer.
4. Additional Documentation: Some insurers may require supplementary documents, such as before-and-after photos of your hair loss.

1. Contact Your Insurer: Call your insurance provider to confirm the required documents and clarify any questions.
2. Submit Your Claim: Use your insurer's recommended method to send your claim form and supporting documents, which may include online portal, email, or mail.
3. Follow Up: Contact your health insurer two to three weeks after submitting your claim to ensure they received it and that you included all required information.
4. Track Your Claim: Maintain a log of all conversations with your health insurance provider, including dates, methods of communication, representative names, reference numbers, and additional documents sent. Use this log as a reference guide when speaking with your insurance provider and continue to follow up regularly until you receive notification of claim approval or denial.

What happens if they deny my claim? If the insurer denies your claim, don’t lose hope. You can (and should!) appeal the decision. 

First, review the denial to understand the reasons for the denial of your claim.  

• Was the claim filed correctly?  
• Was the claim filed for a cranial prosthesis?  
• Does your insurance company understand this is for a medical need, not a “cosmetic”?  
• Did you attach all your documents to the claim?  
• Are there missing codes?  
• Does your insurance company need more information from your retailer? Tax ID? Address? W-9 Form?  
• Is more information needed from your doctor?  

Gather more documents or a more compelling letter from your healthcare provider if needed. If all documents are correct, follow your insurer’s appeal process, and provide all necessary information.¹

¹ source: www.naaf.org

If your insurance does not cover wigs, consider other options:

Health Savings Accounts (HSAs): If you have an HSA, you may be able to use those funds for your wig purchase. 

Community Support: Local groups or online communities can offer resources and funding. 

Nonprofit Organizations: Some groups fund wigs for individuals with alopecia areata or other conditions. These include:¹

¹ source: www.naaf.org