Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Hair Transplants and Cranial Prostheses (Wigs)
Policy #:MA11.046b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

HAIR TRANSPLANTS

When performed as a cosmetic service, hair transplants are not covered by the Company because cosmetic services are not covered by Medicare. However, hair transplants are considered medically necessary and, therefore, covered for the treatment of permanent hair loss that is caused by any of the following conditions:
  • Physical trauma (e.g., burns, lacerations)
  • Surgery (e.g., tumor removal)
  • Diseases that cause cicatricial (scarring) alopecia (e.g., discoid lupus erythematosus, scleroderma)

Hair transplants performed for indications other than those specified in the medical necessity criteria above are considered a cosmetic service. Services that are cosmetic are not covered by the Company because cosmetic services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

CRANIAL PROSTHESES (WIGS)

Cranial prostheses (wigs) are not covered by the Company because they are items not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination for cranial prostheses (wigs). There is no Medicare coverage criteria addressing hair transplants.

BENEFIT APPLICATION

HAIR TRANSPLANTS
Subject to the terms and conditions of the applicable Evidence of Coverage, hair transplants are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

CRANIAL PROSTHESES/WIGS
Subject to the terms and conditions of the applicable Evidence of Coverage, cranial prostheses (wigs) are not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because these services are considered not covered by Medicare.

Description

Alopecia (hair loss) can be caused by aging, hormonal changes, genetic predisposition, or circumstances such as disease or physical trauma. In most disorders of alopecia, the hair follicle is either normal but has an abnormal growth cycle, or it has been damaged. Hair transplants and cranial prostheses (wigs) are frequently used to treat hair loss.

COMMON TYPES OF ALOPECIA

ANAGEN EFFLUVIUM
Anagen effluvium is abnormal diffuse hair loss arising during the growth stage of the hair cycle that may leave the scalp partially or completely bald. The condition begins days to weeks after exposure to a chemotherapeutic agent. It is most apparent after one or two months after chemotherapy administration and is usually reversible with hair regrowth after cessation of the offending chemotherapeutic agent.

ANDROGENIC ALOPECIA
Androgenic alopecia is known as male-pattern baldness in men and female-pattern hair loss in women. It is the most common form of alopecia that results in permanent hair loss. Hair loss is mediated by a combination of genetic factors and levels of testosterone.

ALOPECIA AREATA
Alopecia areata is an autoimmune disease that is characterized by a localized area of complete hair loss that is usually in coin-shaped patches on the face, scalp or other areas of the body that normally grow hair. Thyroid abnormalities and pernicious anemia are frequently the underlying factors of alopecia areata. Alopecia areata encompasses the following types:
  • Patchy alopecia is circumscribed, oval shaped, flesh colored patches on any part of the body.
  • Alopecia totalis involves the entire scalp.
  • Alopecia universalis results in hair loss across the entire scalp, face (including eyebrows and eyelashes), plus the rest of the body (including pubic hair).
  • Diffuse alopecia areata results in sudden and unexpected thinning of the hair all over the scalp.
  • Ophiasis alopecia involves a unique pattern of hair loss which includes the sides and lower back of the scalp, called the occipial region, in the shape of a band.

TELOGEN EFFLUVIUM
Telogen effluvium is a form of hair loss characterized by hair thinning or an increase in hair shedding that arises during the resting stage of the hair cycle especially on the top of the scalp that usually happens after stress, a shock or traumatic event. It is a reactive process occurring more often in women, that resolves spontaneously when the underlying cause is eliminated. A list of inciting factors includes severe, chronic illnesses, pregnancy, high fever, malnutrition, endocrine disorders, severe infections, and emotional and physiologic stress.

CICATRICIAL (SCARRING) ALOPECIA
Cicatricial alopecia refers to a collection of rare hair loss disorders (e.g., folliculitis decalvans, pseudopelade) that result from a condition, such as an infection (e.g., herpes zoster), autoimmune disease ( e.g., discoid lupus erythematosus), sarcoidosis, scalp trauma (e.g., burns), or radiation therapy, that destroys the hair follicle without regrowth, and replaces it with scar tissue, causing permanent hair loss.

TRAUMATIC ALOPECIA
Traumatic alopecia is caused by cosmetic practices that damage hair follicles over time and has been linked to the use of brush rollers, curling irons, tight braiding and repetitive exposure to harsh hair chemicals or disorders such as trichotillomania (compulsive behavior involving the repeated plucking of hair).

HAIR TRANSPLANTS

Hair transplants involve transferring hair follicles from one body site to another for the treatment of conditions such as, but not limited to, alopecia or physical trauma.

There are several types of hair transplant techniques, which include but are not limited to: strip grafts (30 to 40 hairs), punch grafts (10 to 15 hairs), mini-grafts (3 or 6 hairs), and micrografts (1 or 2 hairs).

CRANIAL PROSTHESES (WIGS)

A cranial prosthesis (wig) is a manufactured covering for the head that is made of natural or synthetic hair. The term "wig" also applies to hairpieces and similar manufactured coverings that are used to replace or supplement hair.
References

American Skin Association (ASA). Alopecia. [ASA Web site]. 2012. Available at: www.americanskin.org/resource/alopecia.phys. Accessed April 7, 2020.

American Society for Dermatologic Surgery (ASDS). Hair transplants. [ASDS Web site]. 2019. Available at: https://www.asds.net./skin-experts/skin-treatments/hair-transplants. Accessed April 7, 2020.

American Society of Plastic Surgeons (ASPS). Hair replacement. [ASPS Web site]. 2020. Available at: http://www.plasticsurgery.org/Cosmetic-Procedures/Hair-Replacement.html. Accessed April 7, 2020.

Centers for Medicare & Medicaid Services. Medicare Managed Care Manual Chapter 4-Benefits & Beneficiary Protections. Revised 04/22/2016. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf. Accessed April 7, 2020.

Cicatricial Alopecia Research Foundation (CARF). About cicatricial alopecia. [CARF Web site]. 2019. Available at: http://www.carfintl.org. Accessed April 7, 2020.

Hantash, BM. Scarring alopecia. [Medscape Web site]. 02/26/2018. Available at: http://emedicine.medscape.com/article/1073559-overview. Accessed April 7, 2020.

National Alopecia Areata Foundation (NAAF). Different types of alopecia areata. [NAAF Web site]. 2020. https://www.naaf.org/alopecia-areata/types-of-alopecia-areata. Accessed April 7, 2020.

Noridian Healthcare Solutions. Noncovered items list. Revised 12/19/2019. [Noridian Healthcare Solutions Web site]. Available at: https://med.noridianmedicare.com/web/jadme/search-result/-/view/2230703/noncovered-items. Accessed April 7, 2020.

Phillips TG, Slomiany WP, Allison R. American Family Physician. Hair loss: Common causes and treatment. [American Academy of Family Physicians (AAFP) Web site]. 09/15/2017. Available at: https://www.aafp.org/afp/2017/0915/p371.html. Accessed April 7, 2020.

Springer K, Brown M, Stulberg DL. American Family Physician. Common hair loss disorders. [American Academy of Family Physicians (AAFP) Web site]. 07/01/2003. Available at: http://www.aafp.org/afp/20030701/93.html. Accessed April 7, 2020.

Thiedke CC. Alopecia in women. American Family Physician. [American Academy of Family Physicians (AAFP) Web site]. 03/01/2003. Available at: http://www.aafp.org/afp/20030301/1007.html. Accessed April 7, 2020.

Venes D, Thomas CL, Taber CW, eds. Taber's Cyclopedic Medical Dictionary.19th ed. Philadelphia, PA: FA Davis Co; 2001.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

15775, 15776



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A


HCPCS Level II Code Number(s)



NOT COVERED
A9282 Wig any type, each



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Hair Transplants and Cranial Prostheses (Wigs)
Description: ICD-10 Diagnoses Codes







Policy History

MA11.046b
05/20/2020The policy has been reviewed and reissued to communicate the Company’s continuing position on Hair Transplants and Cranial Prostheses (Wigs).


MA11.046b
09/09/2019The version of this policy will become effective 09/09/2019.

The policy has been updated to communicate the Company's continuing position on Hair Transplants and Cranial Prostheses (Wigs).

The following ICD-10 diagnosis codes have been deleted from the policy:
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
L65.0 Telogen effluvium
L65.1 Anagen effluvium
L65.2 Alopecia mucinosa
L65.8 Other specified nonscarring hair loss
L65.9 Nonscarring hair loss, unspecified

MA11.046a
03/28/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Hair Transplants and Cranial Prostheses (Wigs).
05/03/2017The intent of this policy remains unchanged.

The following code was added:
S01.00XA Unspecified open wound of scalp, initial encounter

MA11.046
03/16/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Hair Transplants and Cranial Prostheses (Wigs).
01/21/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Hair Transplants and Cranial Prostheses (Wigs).
01/01/2015This is a new policy.






Version Effective Date: 09/09/2019
Version Issued Date: 09/09/2019
Version Reissued Date: 05/20/2020