Insurance coverage for scalp cooling is not yet standard in the United States, however DigniCap patients have submitted insurance claims and received reimbursement for treatment costs at varying levels since DigniCap received FDA clearance in 2015. Success with reimbursement varies depending on plan, coverage, and location. With the July 2017 expansion of DigniCap clinical indications to include patients with solid tumors, claims for reimbursement and demand for coverage will continue to build as more patients utilize this life changing treatment at infusion centers across the United States.
For your insurance reimbursement submission:
1. Call your insurance provider to check benefits and obtain a blank claim form. It may be beneficial to ask your provider is they require preauthorization for scalp cooling treatments.
2. The ICD- 10-CM code on your claim form needs to match the diagnosis in your medical record exactly. The primary diagnosis code will likely be in the range of:
0–C96.9 (Malignant neoplasm)
C50-C56 (Malignant neoplasm of breast or female organs)
3. Suggested secondary diagnosis codes are:
Z51.11 (Encounter for antineoplastic chemotherapy)
L65.9 (Nonscarring hair loss unspecified)
4. For patients filing for reimbursement of DigniCap (with their insurance provider), suggested HCPCS codes that may be covered are:
E1399 (durable medical equipment)
A9273 (Ice cap, cold wrap or pack)
Suggested documentation to include with your reimbursement claim:
- Journal of the American Medical Association (JAMA) published scalp cooling study – download it here
- Oncology Research and Treatment published study on Scalp Cooling – download it here
- Ask your doctor for a letter of medical necessity to include in your submission to the insurance company – download sample letter of medical necessity here
- Ask your doctor for progress notes that reference that you are using scalp cooling to include with your claim
You may wish to talk to the financial coordinator at your doctor’s office if you have additional questions about your reimbursement paperwork.
Note that reimbursement may require multiple communications (by phone and in writing) with the insurance company. Insurance coverage varies among individual plans and may be dependent on policy coverage, location, and other factors stipulated by the insurance provider. Co-pays and minimums may also effect any reimbursements, depending on the plan details.
Requesting reimbursement from a third party payer may not result in payment. Scalp cooling service may or may not be covered by the insurance company. Criteria such as co-pays and minimums may be a factor, and the dollar amount of coverage may vary. If it is not covered, no payment would result. Additionally, there may be circumstances where the service is covered and thus can be used on a patient and billed for, but no additional payment would result.
Dignitana has no formal agreement with any Third Party Payer (insurance company) and therefore cannot bill a third party payer on your behalf for scalp cooling services. Coding, coverage, and payment of medical scalp cooling therapeutics for the prevention of chemotherapy-related alopecia has not yet become an industry standard.
To provide patients with financial assistance, Dignitana was a founding partner and continues to be a supporter of HairToStay, a national non-profit foundation that provides subsidies to scalp cooling patients with demonstrated financial need. In addition, some facilities have utilized funding from medical center foundations, community health funds and other philanthropic entities to support scalp cooling in their community.
Please share your experience regarding scalp cooling and insurance by taking the survey at scalpcoolingsurvey.com