CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Wig (Scalp Hair Prosthesis) Coverage — Rhode Island Mandate

Governs coverage of wigs (scalp hair prostheses) for members who experience hair loss as a result of treatment for any form of cancer or leukemia; applies to commercial products and to Rhode Island state-mandated coverage requirements. Does not apply to BlueCHiP for Medicare.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyWig (Scalp Hair Prosthesis) Coverage — Rhode Island Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2007

Next Review DateN/A

Key ActionVerify member eligibility and document that hair loss is related to cancer or leukemia treatment before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$350coverage limit per occurrence / per year

A9282HCPCS code covered

Commercial onlyPlan applicability

2007Policy effective year

Coverage Criteria for Wigs (Scalp Hair Prostheses)

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inv-01: Covered indications

Covered when ALL of the following are met

Coverage conditions: Member has hair loss related to the treatment of any form of cancer or leukemia; Member is covered under a Commercial product (state mandates do not apply to BlueCHiP for Medicare); The expense for the scalp hair prosthesis does not exceed $350 per covered member per year (exclusive of any deductible); Coverage is subject to the same limitations and guidelines as other prostheses specified in the member's plan.

Based on Rhode Island law (RIGL §27-20-54) and federal/state benchmark plan inclusion.

The Rhode Island statutory mandate for scalp hair prostheses does not apply to certain limited‑benefit plans. Specifically, coverage requirements in RIGL §27‑20‑54 exclude: hospital confinement indemnity; disability income; accident only; long‑term care; Medicare supplement; limited benefit health; specified disease indemnity; sickness or bodily injury or death by accident; and other limited benefit policies. Providers should verify member plan type against the subscriber agreement to confirm mandate applicability.

The policy does not establish additional medical necessity criteria for replacement frequency. It notes that, in practice, it is typically not necessary to replace a wig more than once per year. Providers should document clinical need for any replacement that occurs more frequently and confirm member benefits and any limits in the subscriber agreement.

Provider Actions and Operational Requirements

Denial Risk

Limit-based Denials

Claims exceeding the coverage limit of $350 per covered member per year may be denied. This limit is exclusive of any deductible and aligns with Rhode Island statutory requirements for scalp hair prosthesis coverage related to cancer or leukemia treatment.

Coverage limit: $350 per covered member per year (exclusive of deductible)
Limit applies to wigs (scalp hair prosthesis) provided for hair loss due to treatment of cancer or leukemia
Claims above this limit are subject to denial per plan terms

Documentation Required

Billing & Eligibility Documentation

Verify member-specific benefits and eligibility prior to furnishing or billing for a wig (scalp hair prosthesis). Document medical necessity and the diagnosis supporting hair loss due to cancer or leukemia treatment. Maintain records of supplier invoices, prescription or physician recommendation, and any plan-level benefit maximums or member communication about cost-sharing.

Verify eligibility and benefits with BCBSRI provider services before providing the prosthesis
Document diagnosis and clinical rationale that hair loss is due to cancer or leukemia treatment
Retain supplier invoice/receipt and any written physician recommendation or prescription
Inform members in writing if services are non-covered or exceed plan limits and obtain agreement before billing member

Medical Necessity Criteria

inv-11: DME medical necessity

Medical necessity for coverage is established when:

DME necessity: Wig (scalp hair prosthesis) is worn for hair loss suffered as a result of the treatment of any form of cancer or leukemia; Member is covered under a product subject to the Rhode Island mandate (Commercial products); The cost does not exceed $350 per covered member per year.

Policy states no additional medical criteria specified; replacement typically not necessary more than once per year.

Equipment	Purchase / Rental Rule	Coverage limit / Replacement
Wig (scalp hair prosthesis)	Purchase — policy treats wigs as durable medical equipment/prosthesis; no rental provisions specified.	Covered up to $350 per covered member per year; typically not necessary to replace more than once per year.

Replacement Frequency

Wig (scalp hair prosthesis) — Replacement

Replacement intervalPolicy notes it is typically not necessary to replace a wig more than once per year (no more than once per year implied)

Coverage limitCoverage shall not exceed $350 per covered member per year (exclusive of any deductible)

ApplicabilityApplies to wigs worn for hair loss suffered as a result of treatment for any form of cancer or leukemia

Documentation Requirements

Documentation Required

Document diagnosis/treatment-related hair loss and confirm benefits

Document the diagnosis and that the hair loss is related to cancer or leukemia treatment, and confirm member-specific benefits per the subscriber agreement or member certificate before billing.

Retain clinical documentation linking hair loss to cancer or leukemia treatment.
Confirm the member's product is subject to the Rhode Island mandate (applies to Commercial products).

Background

A wig (scalp hair prosthesis) is an artificial covering made of human or synthetic hair worn to conceal baldness. This policy covers wigs when they are worn for hair loss suffered as a result of treatment for any form of cancer or leukemia, consistent with the Rhode Island Benchmark Plan and RIGL §27‑20‑54. Coverage is subject to the same limitations and guidelines that apply to other prostheses under the member's plan and federal EHB rules; federal law also governs removal of annual and lifetime dollar limits. Providers must verify that the hair loss is treatment‑related and that the member's product is subject to the Rhode Island mandate.

Services Not Covered

Wigs are not covered when hair loss is unrelated to treatment for cancer or leukemia. Additionally, the statutory requirement does not extend to members covered under plans explicitly excluded by RIGL §27‑20‑54 (for example, hospital confinement indemnity, disability income, accident‑only, long‑term care, Medicare supplement, limited benefit health, specified disease indemnity, sickness or bodily injury/death by accident, and other limited benefit policies). Providers should confirm coverage and applicable exclusions in the member's subscriber agreement.