CurrentColorado Rocky Mountain Health PlansPolicy ADMINISTRATIVE 296.7

Wigs – Oxford Administrative Policy

Defines Oxford Commercial (Oxford) coverage policy for wigs/scalp hair prostheses governed by applicable state mandates (CT, NY, NJ) including covered indications, exclusions, billing and documentation requirements, and applicable codes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyWigs – Oxford Administrative Policy

Policy CodePolicy ADMINISTRATIVE 296.7

Change TypeRevised (Applicable Codes updated)

Effective DateJan 1, 2026

Next Review Date

Key ActionThe member's treating physician must prescribe the wig (prescription required).

SourceLink

POLICY UPDATE CHANGES

Applicable Codes updated; added multiple ICD-10 diagnosis codes and several T and Z codes.

1Allowed wigs per member (NY, NJ Large)

A9282HCPCS code for wig

MultipleICD-10 codes listed supporting indications

Coverage Summary

This Oxford Commercial policy (Policy Number: ADMINISTRATIVE 296.7, Effective Date/Last Review: January 1, 2026) defines coverage for wigs/scalp hair prostheses per applicable state mandates (Connecticut, New York, New Jersey). It describes covered indications (state-specific criteria for severe hair loss), exclusions and situations where coverage is not available, required billing and documentation (physician prescription, itemized invoice and proof of payment, medical documentation), and applicable codes. Coverage stance is mixed (state-dependent) and the policy applies to Oxford Commercial members.

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Provider Actions & Documentation Requirements

Documentation Required

Physician prescription required

The member's treating physician must prescribe the wig. Include a physician's prescription with the submission to support coverage eligibility.

Documentation Required

Itemized invoice and proof of payment required

Provide an itemized invoice showing price, taxes, and any service charges, plus proof of payment. Acceptable proof of payment examples include a credit card receipt or a copy of a check; an invoice merely marked 'paid' is not sufficient. The invoice must state whether the wig is synthetic or human hair.

Documentation Required

Medical documentation of diagnosis and severity required

Submit medical notes documenting the history and severity of the hair loss and a diagnosis specific to an injury or disease to establish medical necessity.

Documentation Required

Human hair wig allergy documentation

If requesting a human hair wig, include medical documentation that the member is allergic to synthetic wigs (documentation of allergy to synthetic wigs is required).

Billing Rule

Coverage limits for NY and NJ Large groups

Coverage for New York groups and New Jersey large groups is limited to one wig per member, per lifetime. Note that New Jersey small products do not provide coverage for wigs.

Background

This policy defines wig coverage based on State Mandates for Connecticut (CT), New York (NY), and New Jersey (NJ). For CT groups coverage is allowed when a member suffers hair loss due to chemotherapy or radiation therapy and the wig is prescribed by a licensed oncologist. For NY groups and NJ Large groups coverage is allowed when the member has severe hair loss due to injury, disease, or as a side effect of treatment; coverage for NY and NJ Large groups is limited to one wig per member, per lifetime.

The policy also lists exclusions (for example, NJ Small products do not provide coverage; no coverage for repair/replacement for misuse, lost/stolen wigs, hair implants/plugs, human hair wigs unless allergy to synthetic wigs, natural or premature aging (androgenetic alopecia), pregnancy/postpartum alopecia, and styling/coloring). Billing and documentation requirements include a physician prescription, an itemized invoice (stating synthetic or human hair) and proof of payment, and medical notes documenting history, severity, and a diagnosis specific to an injury or disease; human hair wigs require documentation of allergy to synthetic wigs. The policy applies to Oxford Commercial plan membership.

Severe hair loss: Includes conditions such as alopecia areata, alopecia totalis, burns to the scalp, chemotherapy, congenital baldness, lupus, radiation therapy, traumatic injury to the head/scalp, and any condition that results in severe hair loss not listed above.

Revision History

2026-01-01material_changeLatest

Applicable Codes updated: added ICD-10 diagnosis codes L66.0, L66.10, L66.11, L66.12, L66.19, L66.3, L66.4, L66.81, L66.89 and added T- and Z- codes T20.55XD, T20.55XS, T20.65XD, T20.65XS, T20.75XD, T20.75XS, T45.1X5D, and Z79.63; supporting information updated; previous policy version ADMINISTRATIVE 296.6 archived.

2026-01-01policy_effectiveLatest

Policy ADMINISTRATIVE 296.7 became effective (Wigs).

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
L65.1	Anagen effluvium
L65.2	Alopecia mucinosa
L66.0	Pseudopelade
L66.10	Lichen planopilaris, unspecified

OpenPayer

Wigs – Oxford Administrative Policy

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions & Documentation Requirements

Background

Revision History