Cranial/Scalp/Wig Prosthesis Corporate Medical Policy
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This policy governs coverage of wigs or hairpieces used as cranial or scalp prostheses for generalized hair loss, including initial coverage and replacement wigs. It applies to providers submitting claims for eligible members, subject to the member's applicable contract or benefit plan.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Requirements
Initial wig coverage
Covered when generalized hair loss is present due to one or more qualifying conditions.
General coverage requirements
Qualifying cause
- The generalized hair loss is due to chemotherapy.
- The generalized hair loss is due to radiation therapy.
- The generalized hair loss is due to scalp injury.
- The generalized hair loss is due to a third degree burn.
- The generalized hair loss is due to alopecia totalis.
- The generalized hair loss is due to alopecia areata.
- The generalized hair loss is due to congenital baldness present since birth.
Replacement wigs
Replacement wigs are covered when a qualifying replacement circumstance exists and the frequency limit is met.
Replacement wig requirements
Qualifying replacement circumstance
- Normal growth or a significant change in the member's physical condition renders the prosthesis unusable.
- Normal deterioration or natural wear and tear makes the wig unusable.
- The replacement is limited to once every three years.Once every 3 years
The three-year period begins when the original wig is purchased.
Lost, stolen, or destroyed DME replacement
One lost, stolen, or destroyed DME, prosthetic, or orthotic may be replaced per Plan Year when all stated conditions are met.
Lost, stolen, or destroyed item replacement
- The Durable Medical Equipment, prosthetic, or orthotic is not covered by an alternative entity, including but not limited to homeowner's insurance and automobile insurance.
- The item's absence would put the member at risk of death, disability, or significant negative health consequences such as a hospital admission.
- The Durable Medical Equipment is still under warranty.
- No more than one lost, stolen, or destroyed Durable Medical Equipment, prosthetic, or orthotic is replaced per Plan Year.One item per Plan Year
Coverage is not available when the policy’s qualifying conditions for a wig are not met. Hair loss associated with natural aging, premature balding at a young age, male or female pattern baldness, or a medical condition that is not a covered diagnosis under this policy does not qualify.
Replacement of a lost, stolen, or destroyed durable medical equipment item, prosthetic, or orthotic is excluded when the applicable replacement criteria have not been met or when more than one such item is replaced per Plan Year.
A wig is not medically necessary when the policy’s qualifying conditions are not met. It is also not medically necessary for hair loss due to natural aging, premature balding at a young age, male or female pattern baldness, or a medical condition that is not a covered diagnosis under the policy.
Nonqualifying causes include natural aging, premature balding at a young age, and male or female pattern baldness. Hair loss caused by a medical condition that is not a covered diagnosis under this policy is also excluded as not medically necessary.
HCPCS and ICD-10-CM Coding
| A9282 | Wig, Any Type, Each |
| L63.0 | Alopecia (capitis) totalis |
| L63.1 | Alopecia universalis |
| L63.2 | Ophiasis |
| L63.8 | Other alopecia areata |
| L63.9 | Alopecia areata, unspecified |
| L64.0 | Drug-induced androgenic alopecia |
| L64.8 | Other androgenic alopecia |
| L65.1 | Anagen effluvium |
| L65.2 | Alopecia mucinosa |
| L65.8 | Other specified nonscarring hair loss |
| A9282 | Wig, Any Type, Each |
| L63.0 | Alopecia (capitis) totalis |
| L63.1 | Alopecia universalis |
| L63.2 | Ophiasis |
| L63.8 | Other alopecia areata |
| L63.9 | Alopecia areata, unspecified |
| L64.0 | Drug-induced androgenic alopecia |
| L64.8 | Other androgenic alopecia |
| L65.1 | Anagen effluvium |
| L65.2 | Alopecia mucinosa |
| L65.8 | Other specified nonscarring hair loss |
Documentation and Denial Considerations
Stolen-Item Documentation
For a replacement request involving a stolen item, submit supporting documentation with the request.
- Police report or comparable documentation is required.
Medical-Necessity Documentation
Document that generalized hair loss is present and identify the underlying condition supporting medical necessity for the wig.
- Qualifying conditions include chemotherapy, radiation therapy, scalp injury, third-degree burn, alopecia totalis, alopecia areata, and congenital baldness present since birth.
- Supporting ICD-10-CM diagnoses include L63.0, L63.1, L63.2, L63.8, L63.9, L64.0, L64.8, L65.1, L65.2, L65.8, and L66.0 when the policy criteria are met.
Nonqualifying Hair Loss
Expect denial when the qualifying conditions and medical-necessity requirements are not met.
- Nonqualifying causes include natural aging, premature balding at a young age, male or female pattern baldness, and medical conditions that are not covered diagnoses under this policy.
Replacement Limits Not Met
Replacement of a lost, stolen, or destroyed durable medical equipment item, prosthetic, or orthotic is limited to one per Plan Year. Replacement is excluded when the applicable replacement criteria have not been met or when more than one such item is requested in the Plan Year.
- Confirm that the item is still under warranty.
- Confirm that the item is not covered by an alternative entity, including homeowner's or automobile insurance.
- Confirm that the item's absence would put the member at risk of death, disability, or significant negative health consequences, such as hospital admission.
Lost, Stolen, or Destroyed Item Criteria
Before submitting a replacement request for a lost, stolen, or destroyed item, verify that it is not covered by an alternative entity, remains under warranty, and that its absence creates the specified serious health risk.
- The replacement rule applies to one lost, stolen, or destroyed durable medical equipment item, prosthetic, or orthotic per Plan Year.
- For stolen items, include documentation such as a police report with the request.
Policy Background
A wig or hairpiece, also called a cranial or scalp prosthesis, is a prosthetic supply made with human or artificial hair. It may be worn as personal adornment or to conceal baldness. Coverage under this policy focuses on generalized hair loss associated with specified medical conditions or treatments rather than cosmetic or age-related hair loss.
Key Definition
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