Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Hair Transplants and Cranial Prostheses (Wigs)

Policy #:11.08.01f

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

HAIR TRANSPLANTS

When performed as a cosmetic service, hair transplants are a benefit contract exclusion for all products of the Company and are not eligible for reimbursement consideration. 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 cosmetic and, therefore, a benefit contract exclusion.

CRANIAL PROSTHESES (WIGS)

Wigs are a standard benefit contract exclusion for most products of the Company. When a benefit exists, wigs are covered and eligible for reimbursement consideration by the Company according to the criteria specified in the group benefit contract. If the group benefit contract does not provide specific criteria for the coverage of wigs, they are covered when all of the following criteria are met:
  • The member's purchased group benefit includes coverage of wigs, and the service is provided within the scope of the member's benefit contract.
  • The wig has been ordered by a professional provider.
  • Significant hair loss exists, with a projected duration of at least six months, due to a condition or injury such as, but not limited to:
    • Alopecia universalis/alopecia totalis
    • Alopecia areata
    • Burns
    • Chemotherapy/radiation therapy
    • Traumatic or surgical scalp avulsions

The Company does not provide benefits for wigs or other items that are intended to replace hair loss associated with either of the following:
  • Male-pattern baldness/female-pattern hair loss
  • Cosmetic purposes

When a benefit exists, coverage limitations for wigs, repair and replacement, and dollar amount related to lifetime and/or annual maximums vary by product or by group; therefore, individual member benefits must be verified.

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 health care professional'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.

All requests for hair transplants require review by the Company and must include color photographs and a letter of medical necessity from the provider.
Guidelines

BENEFIT APPLICATION

HAIR TRANSPLANT
Subject to the terms and conditions of the applicable benefit contract, hair transplants are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

CRANIAL PROSTHESES (WIGS)
Subject to the terms and conditions of the applicable benefit contract, wigs are a standard benefit contract exclusion for all products of the Company except Major Medical. However, when purchased as a group benefit, wigs are covered under the medical benefits of the Company's products. Individual benefits must be verified.

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

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, which can extend to the entire scalp (alopecia totalis) or the entire body (alopecia universalis).

TELOGEN EFFLUVIUM
Telogen effluvium is characterized by diffuse hair shedding caused by metabolism, hormones, stress, or medication. It is a reactive process that resolves spontaneously.

CICATRICIAL (SCARRING) ALOPECIA
Cicatricial alopecia refers to a collection of rare hair loss disorders 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 results from cosmetic practices (e.g., 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 (three or six hairs), and micrografts (one or two 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.

COSMETIC SERVICES

Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement does not constitute improvement in physiologic function.
References


American Society of Plastic Surgeons (ASPS). Hair replacement. [ASPS Web site]. 2012. Available at: http://www.plasticsurgery.org/Cosmetic-Procedures/Hair-Replacement.html. Accessed January 29, 2018.

Company Benefit Contracts.

Hantash, BM. Scarring alopecia. [Medscape Web site]. Updated: Feb 26, 2016. 10/18/12. Available at: http://emedicine.medscape.com/article/1073559-overview. Accessed January 29, 2018.

Springer K, Brown M, Stulberg DL. American Family Physician. Common hair loss disorders. [American Academy of Family Physicians (AAFP) Web site]. 07/01/03. Available at: http://www.aafp.org/afp/20030701/93.html. Accessed January 29, 2018.

Thiedke CC. Alopecia in women. American Family Physician. [American Academy of Family Physicians (AAFP) Web site]. 03/01/03. Available at: http://www.aafp.org/afp/20030301/1007.html. Accessed January 29, 2018.

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)

MEDICALLY NECESSARY

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-CM codes




Policy History

Revisions from 11.08.01f
03/28/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Hair Transplants and Cranial Prostheses (Wigs).


Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 05/03/2017
Version Issued Date: 05/03/2017
Version Reissued Date: 03/28/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.