CurrentBlue Cross Complete of MichiganPolicy N/A

Wig Coverage

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This Medicare Advantage enhanced benefit policy governs coverage, payment conditions, coding, billing, and member cost sharing for wigs prescribed for eligible hair-loss conditions. It applies to BCN Advantage group HMO members and participating providers.

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyWig Coverage

Policy CodePolicy N/A

Change TypeRevised

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSeek a coverage determination from BCN Advantage before providing an item when coverage is uncertain.

SourceLink

POLICY UPDATE CHANGES

The policy history states that the diagnosis code set was updated to include the listed alopecia and hair-loss diagnoses.

3Restricted CPT/HCPCS codes

24Eligible ICD-10 diagnosis codes

Physician prescriptionPrescription requirement

HomePayable location

No restrictions

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CurrentBlue Cross Complete of MichiganPolicy N/A

Wig Coverage

Customize your policy alerts

Sign up for all blue_cross_complete_of_michigan policy alerts

Know when blue_cross_complete_of_michigan releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Complete of Michigan

PolicyWig Coverage

Policy CodePolicy N/A

Change TypeRevised

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSeek a coverage determination from BCN Advantage before providing an item when coverage is uncertain.

SourceLink

POLICY UPDATE CHANGES

The policy history states that the diagnosis code set was updated to include the listed alopecia and hair-loss diagnoses.

3Restricted CPT/HCPCS codes

24Eligible ICD-10 diagnosis codes

Physician prescriptionPrescription requirement

HomePayable location

No restrictions

Coverage Criteria

Wig coverage

Covered for payment when all applicable requirements are met.

Wig coverage requirements

Prescription and qualifying condition
- The wig is prescribed by a physician.
- Qualifying hair-loss condition
  - Hair loss is due to chemotherapy.
  - The member has alopecia or a disease that caused hair loss.
Coding requirements
- Restricted CPT/HCPCS code
  - The billed item uses HCPCS code A4452, A4649, or A9282.
- Restricted ICD-10 diagnosis
  - The diagnosis is one of the listed ICD-10 codes: L63.0, L63.1, L63.2, L63.8, L63.9, L64.0, L64.8, L64.9, L65.0, L65.1, L65.2, L65.8, L65.9, L66.0, L66.10, L66.11, L66.12, L66.19, L66.2, L66.3, L66.4, L66.81, or L66.9.

Original Medicare noncoverage: Wigs of any type, wig stands, and wig-related adhesives are not covered under Original Medicare for any reason or condition. Coverage under the BCN Advantage enhanced benefit is subject to the separate applicable eligibility and payment requirements.

Billing and Diagnosis Codes

Covered CPT/HCPCS CodesHCPCSCovered

A4452	Tape, waterproof, per 18 sq in.
A4649	Surgical supply; miscellaneous.
A9282	Wig, any type, each

Covered ICD-10 CodesICD-10Covered

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.
L64.9	Androgenic alopecia, unspecified.
L65.0	Telogen effluvium.
L65.1	Anagen effluvium.

1–10 of 23

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Provider Actions and Billing Responsibilities

Prior Authorization

Coverage Determination When Coverage Is Uncertain

If coverage for a wig or other item is uncertain, seek a coverage determination from BCN Advantage before providing the item to the member.

Documentation Required

Prescription and Qualifying Condition Required

A physician must prescribe the wig, and the medical record must document a qualifying condition causing hair loss.

Hair loss due to chemotherapy.
Alopecia or a disease that caused hair loss.

Documentation Required

Policy Background

A wig is an artificial covering of hair for all or most of the head and may be made from synthetic or natural hair. Original Medicare does not cover wigs, wig stands, or wig-related adhesives; the BCN Advantage enhanced benefit provides coverage for a wig only when the applicable requirements are met, including a physician prescription, qualifying hair loss due to chemotherapy or alopecia or another disease, and the applicable code restrictions.

Definitions

Wig

DefinitionAn artificial covering of hair for all or most of the head made of either synthetic or natural hair.

Medical Necessity Requirements

Required Documentation

Documentation Required

Obtain a physician prescription for the wig

A physician prescription is required. The prescription should identify the wig and support hair loss due to chemotherapy or alopecia or a disease that caused hair loss.

Billing Rule

Submit complete claim documentation

Submit the applicable CPT/HCPCS and diagnosis codes at the highest level of specificity, include the provider’s National Provider Identifier on all claims, and support billed claims with medical records when required.

Applicable CPT/HCPCS codes: A4452, A4649, or A9282.
Use one of the policy’s listed ICD-10 diagnosis codes.

Noncovered Items

Not covered: Original Medicare does not cover wig stands or wig-related adhesives for any reason or condition. Wigs are also not payable under the enhanced benefit when the member does not have qualifying hair loss due to chemotherapy, alopecia, or another disease causing hair loss, or when the prescription, procedure code, or diagnosis code requirements are not met.

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyWig Coverage

Policy CodePolicy N/A

Change TypeRevised

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSeek a coverage determination from BCN Advantage before providing an item when coverage is uncertain.

SourceLink

On This Page

Support Claims With Complete Coding and Documentation

Submit claims using the applicable claim form or electronic equivalent, BCN Advantage billing requirements, and the applicable CPT/HCPCS and diagnosis codes at the highest level of specificity. Include the billing provider’s National Provider Identifier (NPI) on every claim and provide supporting medical records or other documentation when required.

Bill on the CMS-1500 (02/12), UB-04, or 837 equivalent claim form.
Report applicable CPT/HCPCS codes and diagnosis codes with the highest level of specificity.
Send claims to BCN Advantage and follow applicable BCBSM reimbursement policies and provider-manual requirements.

Denial Risk

Missing Prescription or Eligible Diagnosis

Payment may be denied when the required physician prescription is absent or when the member does not have a qualifying hair-loss condition documented.

Qualifying diagnosis restrictions include the listed alopecia and other hair-loss diagnoses, including L63.0, L63.1, L63.2, L63.8, L63.9, L64.0, L64.8, L64.9, L65.0, L65.1, L65.2, L65.8, L65.9, L66.0, L66.10, L66.11, L66.12, L66.19, L66.2, L66.3, L66.4, L66.81, and L66.9.

Denial Risk

Noncovered or Uncertain Items

A member who elects a noncovered service is responsible for the entire charge. However, providers may not have members sign an Advance Beneficiary Notice of Noncoverage for noncovered items; if an item is furnished without first obtaining a required coverage determination, the member must be held harmless for all charges other than any applicable cost share.

Obtain a BCN Advantage coverage determination before furnishing an item when coverage is in question.
Do not use an Advance Beneficiary Notice of Noncoverage to transfer responsibility for a noncovered item.

Billing Rule

No Balance Billing or Incorrect Cost Sharing

Collect only the applicable BCN Advantage cost sharing. Payment is the lesser of the plan’s allowed amount or the provider’s charge, minus the member’s cost share, and is payment in full; do not balance bill the member for the difference.

Cost sharing may be a copayment, coinsurance, or deductible.
Verify benefits and cost sharing through the provider portal or by calling 1-800-344-8525.
Providers may not collect amounts beyond the appropriate BCN Advantage cost sharing or the permitted payment arrangement.