CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Wig Mandate (Wigs / Scalp Hair Prosthesis) Coverage Criteria

Covers wigs or toupees (scalp hair prosthesis) for hair loss resulting from treatment of cancer or leukemia for BCBSRI members; includes Medicare Advantage (BlueCHiP for Medicare) and commercial products with applicable limits and benefit-booklet variance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyWig Mandate (Wigs / Scalp Hair Prosthesis) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2007

Next Review DateN/A

Key ActionVerify member benefit and eligibility prior to providing a wig and obtain written agreement before billing the member for non-covered items.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$350annual maximum ($)

A9282HCPCS covered

2007effective

2019-03-05last updated

Coverage criteria

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Coverage conditions: Member has hair loss related to treatment of any form of cancer or leukemia.

See Rhode Island statute limiting coverage to $350 per covered member per year; subject to same limitations/guidelines as other prostheses.

Coverage conditions: Item provided is a wig or toupee (scalp hair prosthesis) intended to conceal hair loss.

Definition: artificial covering made of human or synthetic hair worn on the head to conceal baldness.

Coverage conditions: Coverage does not exceed $350 per covered member per year (exclusive of any deductible).<= $350 per member per year

Applies to BlueCHiP for Medicare and Commercial members unless excluded by plan type or contract.

Coverage conditions: Coverage is subject to the same limitations and guidelines that apply to other prostheses under the member's plan.

Self-funded groups and certain limited‑benefit plans may be excluded; verify member benefit documents.

The statutory requirement for scalp hair prosthesis does not apply to certain limited-benefit plans. Specifically, 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 are excluded from this mandate.

Coding and limits

Covered HCPCS CodesHCPCSCovered

A9282

Wig, any type, each

inv-05: Annual maximum — $350 per covered member per year

Annual maximum$350 per covered member per year (exclusive of any deductible)

Applicable plansIndividual and group hospital or medical expense policies and service plan contracts delivered, issued for delivery, or renewed in RI on/after 2007-01-01

Limit applicationSubject to same limitations and guidelines as other prostheses

Provider actions and billing

Note

Prior Authorization

Not applicable

Note

Provider action (callout placeholder)

Note

Benefit variability

Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable durable medical equipment/prosthesis coverage. Self-funded groups may or may not choose to follow state mandate(s). Due to the language in the state mandate, and for the purposes of this policy only, wigs are referred to as durable medical equipment/prosthesis.

Billing Rule

Member-specific benefits and billing

For information on member-specific benefits, call the provider call center or refer to the member's subscriber agreement, Evidence of Coverage, or Benefit Booklet. Providers may not bill members for services or items that are covered under the member's plan unless the provider has informed the member and obtained their written agreement in advance. Benefits and eligibility are determined by the member's subscriber agreement, member certificate, and/or the employer agreement, which supersede this policy.

Medical necessity

Medical necessity for wig coverage

Medical necessity tied to cause of hair loss

Necessity: Hair loss must be related to the treatment of any form of cancer or leukemia.

Statutory requirement: coverage limited to hair loss suffered as a result of cancer or leukemia treatment.

Necessity: The wig is intended to conceal that hair loss (scalp hair prosthesis).

Wig or toupee defined as an artificial covering made of human or synthetic hair worn on the head to conceal baldness.

Definitions

inv-11: Wig or toupee (scalp hair prosthesis) — definition of the prosthesis

DefinitionAn artificial covering made of human or synthetic hair worn on the head to conceal baldness (scalp hair prosthesis).

Intended useWorn to conceal hair loss suffered as a result of the treatment of any form of cancer or leukemia.

TerminologyAlso referred to as a wig or toupee (scalp hair prosthesis).

Rental and purchase rules

Item	Purchase vs Rental	Limit / Notes
{"text":"Wig (scalp hair prosthesis)","status":""}\|{"text":"Purchase","status":""}\|{"text":"Covered as a purchase benefit up to $350 per covered member per year; coverage applies when hair loss is related to treatment of any form of cancer or leukemia. Typically not necessary more than once per year.","status":""}

Replacement frequency

inv-14: Wig — Not typically necessary more than once per year

Replacement frequencyNot typically necessary to replace a wig more than once per year.

Coverage implicationReplacement frequency aligns with statutory guidance and annual maximum limits.

Clinical noteTypical clinical need does not require more than one replacement per year for scalp hair prostheses.

Documentation and verification

Documentation Required

Verify eligibility and obtain written agreement for non-covered billing

Verify member benefit and eligibility prior to providing a wig and obtain the member's written agreement before billing them for any items or services determined to be non-covered.

Refer to the member's Benefit Booklet, Evidence of Coverage, Subscriber Agreement, or employer agreement for benefit specifics.
Contact the provider call center for member-specific verification.
Do not bill the member for non-covered services unless they have provided written agreement in advance.

Background

Wigs (scalp hair prosthesis) are artificial head coverings made of human or synthetic hair worn to conceal baldness. Coverage under this policy is limited to wigs worn for hair loss suffered as a result of treatment for any form of cancer or leukemia. Coverage is provided subject to the same limitations and guidelines that apply to other prostheses and is capped at $350 per covered member per year. The requirement is included in the Rhode Island Benchmark Plan for Qualified Health Plans and applies to applicable BlueCHiP for Medicare and commercial products unless excluded by the member's plan type or contract. Replacement is typically not necessary more than once per year.

Not covered

Wigs provided for causes other than hair loss resulting from the treatment of cancer or leukemia are not covered under this mandate. Additionally, the statute does not apply to certain limited-benefit insurance types (see exclusions), so wigs for non-cancer-related hair loss under those plans are also not covered.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyWig Mandate (Wigs / Scalp Hair Prosthesis) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2007

Next Review DateN/A

Key ActionVerify member benefit and eligibility prior to providing a wig and obtain written agreement before billing the member for non-covered items.

SourceLink

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