Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 01|01|2007 POLICY LAST REVIEWED: 09|25|2025

OVERVIEW A wig or toupee is an artificial covering made of human or synthetic hair worn on the head to conceal baldness. This policy documents coverage for wigs (scalp hair prosthesis) worn for hair loss suffered as a result of the treatment of any form of cancer or leukemia in accordance with federal and state mandates (see text below). This policy is applicable to Commercial products as State Mandates do not apply to Medicare Advantage Plans.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
Not applicable

POLICY STATEMENT Commercial Products Wigs or toupees are covered at $350 per occurrence for members who have hair loss related to the treatment of cancer or leukemia.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet or Subscriber Agreement for applicable durable medical equipment/prosthesis coverage.

Self-funded groups may or may not choose to follow state mandate(s). Due to the language in the state mandate, and for the purposes of this policy only, wigs are referred to as durable medical equipment/prosthesis.

BACKGROUND Qualified Health Plans (QHPs) are required to cover Essential Health Benefits (EHBs), as defined in Section 1302(b) of the Patient Protection and Affordable Care Act. http://www.ncsl.org/issues- research/health/state-ins-mandates-and-aca-essential-benefits.aspx - 5 Most benefit plans will need to include these EHBs (some exceptions may apply to certain large groups; consult your Subscriber Agreement for details).

Wigs (scalp hair prosthesis) worn for hair loss suffered as a result of the treatment of any form of cancer or leukemia, are included in the Rhode Island Benchmark Plan that defines the EHBs for RI QHPs. Federal mandates regarding EHBs supersede RI state mandates in regard to removing any annual and lifetime dollar limits.

According to Rhode Island General Law (RIGL) Section 27-20-54 for Mandatory coverage of scalp hair prosthesis:

Payment Policy | Wig Mandate

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

(a) Every individual or group hospital or medical expense insurance policy or individual or group hospital or medical services plan contract delivered, issued for delivery, or renewed in this state on or after January 1, 2007, which provides coverage for any other prosthesis shall provide coverage for expenses for scalp hair prosthesis worn for hair loss suffered as a result of the treatment of any form of cancer or leukemia; provided, however, that such coverage shall be subject to the same limitations and guidelines as other prosthesis, and that coverage shall not exceed an amount of three hundred fifty dollars ($350) per covered member per year, exclusive of any deductible.

(b) This section shall not apply to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability income; (3) accident only; (4) long-term care; (5) Medicare supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both; and (9) other limited benefit policies.

Please note: It is typically not necessary to replace a wig more than once a year.

CODING Commercial Products The following HCPCS code is covered for members with a diagnosis of cancer: A9282 Wig, any type, each

RELATED POLICIES: Not applicable

PUBLISHED Provider Update, September 2023 Provider Update, Dec 2021 Provider Update, May 2020 Provider Update, May 2019 Provider Update, April 2018 Provider Update, May 2017

REFERENCES

1. NCSL National Conference of State Legislatures STATE HEALTH INSURANCE MANDATES AND THE ACA ESSENTIAL BENEFITS PROVISIONS: http://www.ncsl.org/issues-research/health/state-ins-mandates-and-aca-essential-benefits.aspx

2. Rhode Island General Law (RIGL) § 27-20-54 Mandatory coverage for scalp hair prosthesis:
   http://webserver.rilin.state.ri.us/Statutes/title27/27-20/27-20-54.HTM

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS