Maximizing Insurance Coverage For Cranial Prosthesis: A Comprehensive Guide

A cranial prosthesis is a wig designed for people with hair loss due to medical conditions such as alopecia, chemotherapy, or other clinical treatments. Many insurance companies will cover the cost of a cranial prosthesis, but the process to obtain coverage varies. First, it is important to determine whether your insurance policy covers cranial prostheses and what type (e.g. human hair or synthetic) is included. Then, you will need a prescription from your doctor using the specific terminology required by your insurance provider. This prescription should not refer to the cranial prosthesis as a wig, as wigs are often considered cosmetic rather than medical. Keeping a paper trail of all documentation, invoices, and correspondence is also important when seeking reimbursement for a cranial prosthesis.

Know the terminology: use 'cranial prosthesis' or 'cranial hair prosthesis' instead of 'wig'

When seeking insurance coverage for a cranial prosthesis, it is important to use the correct terminology. While the term "wig" may be commonly used and understood, insurance companies may deny coverage for wigs as they are considered fashion items and therefore not medically necessary. Instead, use the term "cranial prosthesis" or "cranial hair prosthesis" to emphasise the medical nature of the device.

A cranial prosthesis is a custom-made wig designed for individuals experiencing hair loss due to medical conditions or treatments. It is considered a medical device, and as such, full or partial coverage of the cost may be available through many medical insurance companies. By using the term "cranial prosthesis" when corresponding with insurance providers, you reinforce the medical necessity of the device and increase the likelihood of coverage.

Other terms that can be used interchangeably with "cranial prosthesis" include "hair prosthesis", "full cranial prosthesis", "extra-cranial prosthesis", and "cranial hair prosthetic". These terms all convey the medical purpose of the device, distinguishing it from a traditional wig used for cosmetic reasons.

When obtaining a prescription from your doctor, ensure that they use the appropriate terminology required by your insurance provider. The prescription should include the medical procedure code A9282 and avoid any mention of "wig" to ensure that your insurance claim is not denied on the grounds that the device is cosmetic rather than medical.

In addition to the prescription, your doctor can also write a letter explaining the impact of hair loss on your emotional well-being. This can further emphasise the medical necessity of the cranial prosthesis and strengthen your insurance claim. Remember to keep copies of all documentation, including the prescription, invoices, and correspondence, for tax exemption purposes and to facilitate the insurance claim process.

Check your insurance contract for coverage

To check if your insurance contract covers cranial prostheses, you'll need to carefully review your full health insurance contract—not just the summary of benefits you received when you first signed up. Look specifically for sections about prosthesis coverage. If you can't find any mention of prostheses, don't assume that you're not covered. Many policies don't spell out exclusions under prostheses, and applying for prosthesis coverage may be your best chance of having your claim accepted.

Once you've located the relevant section of your insurance contract, look for answers to the following questions:

• Does your policy cover a cranial prosthesis? Note that it's important to use the term "cranial prosthesis" or "cranial hair prosthesis" rather than "wig" when discussing this topic with your insurance company, as wigs are typically considered cosmetic products that aren't covered by insurance.
• If it does, what type of prosthesis is covered (e.g. human hair wigs, synthetic wigs)?
• How much of the cost do they cover?
• Is pre-approval required for coverage, and if so, what documentation is needed?
• What specific documentation will you need when filing your claim?

If you're unsure about any of the above, contact your insurance company's toll-free number and ask them to clarify.

Contact your insurance company to ask about coverage

Before you begin the process of purchasing a cranial prosthesis, it is important to contact your insurance company to understand the extent of your coverage. The first step is to obtain a copy of your full health insurance contract and review the section about prosthesis coverage. This will give you a sense of whether your insurance plan includes coverage for cranial prostheses.

Once you have reviewed your insurance contract, the next step is to call the toll-free number on your insurance card. Ask the representative if your policy covers a "cranial prosthesis" and how much of the cost the policy will cover. It is important to use the term "cranial prosthesis" or "cranial hair prosthesis" rather than "wig" when discussing coverage with your insurance company, as wigs are typically considered cosmetic products that are not covered by insurance.

If your policy does cover cranial prostheses, ask about the type of prosthesis that is covered. For example, does the insurance cover human hair wigs, synthetic wigs, or both? Additionally, inquire about whether you need pre-approval for coverage and what documentation is required for that pre-approval. Understanding the specific requirements will help ensure a smooth process when filing your claim.

Another important question to ask is whether you need to use specific terminology on the prescription for the cranial prosthesis. Ask your insurance company what specific wording or procedure codes are needed on the prescription to ensure coverage. For example, the procedure code A9282 is often used for cranial prostheses.

Finally, ask about the documentation you will need when filing your claim. This may include a doctor's prescription, a completed insurance claim form, invoices or receipts, and any other relevant correspondence. Keeping a paper trail and making copies of all documentation will help ensure that you have everything you need when submitting your claim.

Get a prescription from your doctor, using the correct terminology

To get a prescription from your doctor, it is important to use the correct terminology to ensure that your insurance provider recognises your cranial prosthesis as medically necessary.

Firstly, it is important to note that the term 'wig' should be avoided, as wigs are considered fashion items and are therefore not medically necessary. Instead, the terms 'cranial prosthesis', 'hair prosthesis', 'full cranial prosthesis', 'cranial hair prosthesis', or 'extra-cranial prosthesis' should be used. The specific term that your insurance provider requires may be found in your insurance contract, or you can call your insurance provider to ask.

Secondly, the prescription should include the procedure code A9282. This is used to submit your insurance claim. Other common CPT codes for the reimbursement/billing of a cranial prosthesis include D5924 and S8095.

Thirdly, it is recommended that you ask your doctor to write a letter explaining the effects of hair loss and confirming that the cranial prosthesis is not for cosmetic reasons but for your emotional well-being. This adds a personal touch and makes it clear that the cranial prosthesis is medically necessary.

Finally, make sure to keep copies of all your documentation and invoices from your doctor, as these will be needed for tax exemption purposes and to submit your insurance claim.

Submit the prescription, a completed claim form, and the receipt to your insurance company

Once you have obtained a prescription from your doctor, the next step is to submit the relevant documentation to your insurance company. This typically includes the prescription, a completed claim form, and the receipt for your cranial prosthesis.

It is important to ensure that the prescription uses the correct terminology required by your insurance provider. The term "cranial prosthesis" or "cranial hair prosthesis" is typically preferred over the term "wig", as wigs are often considered cosmetic items rather than medical devices. The procedure code/number A9282 is also important to include on the prescription, as this is used to submit your insurance claim.

In addition to the prescription, you will need to complete a claim form provided by your insurance company. This form will include details such as the type of prosthesis being claimed, the cost, and any relevant medical information.

Finally, you will need to provide a receipt for your cranial prosthesis purchase. This receipt should include a proper itemized bill of sale, with a valid taxpayer number and NPI number. It is also important to keep a copy of all documentation for your records, in case there are any delays or issues with your claim.

By submitting these documents to your insurance company, you can initiate the process of reimbursement for your cranial prosthesis. It is important to note that the specific requirements and coverage may vary depending on your insurance provider and policy, so it is always recommended to contact them directly to confirm the necessary steps and eligibility for coverage.

Frequently asked questions