CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Wigs (scalp hair prosthesis) for cancer treatment-related hair loss

Policy governing coverage of wigs (scalp hair prostheses) for members who experience hair loss due to treatment for any form of cancer or leukemia; applies to Commercial products and Rhode Island Essential Health Benefit plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyWigs (scalp hair prosthesis) for cancer treatment-related hair loss

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2007

Next Review DateN/A

Key ActionVerify member eligibility and benefits via the subscriber agreement and document cancer treatment-related hair loss when submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$350coverage amount

A9282covered HCPCS

2007-01-01effective

1/yrreplacement

Coverage Criteria

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Primary coverage conditions: Member has hair loss related to the treatment of any form of cancer or leukemia; the item is a scalp hair prosthesis (wig or toupee); coverage is subject to the same limitations and guidelines as other prostheses under the member's plan.

Applies to Commercial products and Rhode Island Essential Health Benefit plans; federal/state mandates and plan exclusions may affect applicability.

The Rhode Island statute specifies certain plan types that are excluded from the mandatory coverage requirement for scalp hair prostheses. Specifically, coverage requirements do not apply to policies that provide only: hospital confinement indemnity, disability income, accident-only coverage, long-term care, Medicare supplement, limited benefit health plans, specified disease indemnity, plans providing only benefits for sickness or bodily injury or death by accident, or other limited benefit policies.

Provider Actions

Prior Authorization

Prior authorization is not applicable for this policy.

Step Therapy

Step therapy / Medical Criteria

No medical criteria or step therapy requirements are specified for coverage of scalp hair prosthesis under this policy.

Documentation Required

Benefit Verification and Documentation

Providers should verify member eligibility and benefits using the member's subscriber agreement / member certificate and employer agreement; these documents govern benefits and supersede this policy. For member-specific benefits or questions, contact the provider call center. If services are determined to be not medically necessary or are non-covered benefits, providers may not charge the member unless the member was informed and agreed in writing to pay. This policy is informational and not a guarantee of payment.

Verify eligibility and benefits via subscriber agreement / member certificate and employer agreement.
Contact the provider call center for member-specific coverage questions.
Do not bill the member for non-covered or not medically necessary services unless the member provided prior written agreement to pay.

Note

Eligibility Limitation

Coverage is limited to scalp hair prostheses (wigs) worn for hair loss suffered as a result of the treatment of any form of cancer or leukemia, subject to the same limitations and guidelines as other prostheses and any applicable member cost-sharing; typically replacement more than once per year is not necessary.

Background

Wigs (scalp hair prostheses) are artificial coverings made of human or synthetic hair worn on the head to conceal baldness. This policy addresses coverage for scalp hair prostheses when hair loss is suffered as a result of the treatment of any form of cancer or leukemia. Coverage follows Rhode Island law (RIGL Section 27-20-54) and the Rhode Island Essential Health Benefits benchmark for Qualified Health Plans; policy coverage is subject to the same limitations and guidelines that apply to other prostheses under the member's plan.

DME Medical Necessity

Medical necessity for DME coverage is defined by:

DME necessity nodes: Wig is worn for hair loss suffered as a result of treatment of any form of cancer or leukemia; the member's plan provides prosthesis coverage and applies the same limitations and guidelines as other prostheses; covered HCPCS code A9282 is used.

Commercial products have a per-occurrence allowance (e.g., $350); replacement is typically not needed more than once per year; some group contracts or self-funded plans may be exempt from state mandates.

Item	Purchase rules / allowance	Notes
Wig (scalp hair prosthesis)	Covered as a purchase at $350 per occurrence for Commercial products	Coverage applies when hair loss is related to treatment for cancer or leukemia; benefit amount and applicability vary by contract and plan.

Replacement

Wig — replacement frequency

Typical replacement frequencyApproximately once per year (policy notes it is typically not necessary to replace a wig more than once per year).

Commercial allowanceCommercial products covered at $350 per occurrence (allowance applies per occurrence).

Replacement contextReplacement frequency guidance applies when wig is worn for hair loss due to cancer or leukemia treatment and is subject to plan benefits.

Documentation

Documentation Required

Document diagnosis and treatment context and verify benefits

Confirm member benefits and eligibility via the subscriber agreement or member certificate; maintain documentation that supports the diagnosis and treatment context (i.e., hair loss related to cancer or leukemia treatment) and make it available per the member's plan requirements.

Document that the wig is for hair loss resulting from treatment of cancer or leukemia.
Retain benefit verification (subscriber agreement/member certificate) and be prepared to produce it if requested.

Not Covered

Wigs provided solely for cosmetic reasons or to conceal baldness not related to treatment for cancer or leukemia are not covered under this mandate. Coverage is limited to scalp hair prostheses worn for hair loss suffered as a result of cancer or leukemia treatment and is subject to the member's plan provisions.