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Insurance claim for medical hair prosthesis
I am curious how others may have fared when putting in a claim with their medical provider for a medical hair prosthesis (aka wig ). I submitted a claim for my daughter's on the recommendation of the provider and United Healthcare has been trying to make my life miserable by asking for one thing and once you provide it they ask for another. Most recently they asked for a letter from the doctor which she was kind enough to provide about the overall condition. Then they wanted a letter from the dermatologist about the expected permanency as it she had a crystal ball which we got and yesterday they asked for CPT/HCPC procedure and diagnostic codes. My wife seems to think that is a positive as it would appear they plan on paying the claim but I think its another excuse to discourage us from proceeding. Unfortunately, they picked the wrong person if they think that will happen. Anyone else have an experience they wish to share?
Replies to This Discussion
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Permalink Reply by Emory on -
I haven't submitted to the insurance company because I have United Healthcare Oxford and they are one of toughest insurance companies. I am a breast cancer surgeon so i know a bit about insurance companies. Unfortunately, the steps they are putting you through are pretty standard. Anyway, the ICD-9 diagnosis code for alopecia is 704.00. The CPT procedure code is only required if the dermatologist did a biopsy or some other procedure. If you need a code for a specific procedure, let me know, I have a diagnosis and procedure coding book in my office (google works too). Anyhow, I hope this helps.
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Permalink Reply by Tony on -
Emory:
I spent a few hours on the internet today trying to research this before I saw your email. According to several sites, they suggested NOT using code A9282 as that is the code for "Wigs, any type" and the mere reference to the word wig will result in a denial. A couple of sites suggested using code CPT-ORN-1 but they don't mention what that refers to and I couldn't find it. Would you know? The guy at the wig store also mentioned that using anything that ties into the word wig is a no-no and said Blue Cross was good at paying but United Healthcare gave all his customers a hard time. He uses the term cranial hair prosthesis on his paperwork so that is helpful. Thanks for your help.
Tony
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Permalink Reply by cathy clark on
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Yes, cranial hair prosthesis. You really want to differentiate your condition from those who have more of a cosmetic problem-i.e. really bad hair, (although we all know how distressing that condition is-but it won't get you insurance coverage) from those who have no hair or almost no hair, at least not enough to be able to go to school or work without a prosthesis.The reality is that a doctor will only write a letter or prescription for someone who needs a wig because of total or severe alopecia, but insurance companies don't trust doctors-they think doctors are just a bunch of wimps-too rushed to make good decisions-with a prescription pad at their finger tips as they rush people out of the office.
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Permalink Reply by Leslie Mader on
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I have Blue Cross/Blue Shield and they do not cover medical or cranial prothetics. It's not in our "plan" and from what i hear not many have coverage for wigs. It's a shame! Good Luck!
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Permalink Reply by Tony on
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According to the wig store, at least in NJ, Blue Cross does pay subject to monetary limitations. He thought it was up to $300. It also appears that the State of Delaware mandates that a carrier must pay up to $500 for a cranial prosthesis if deemed medically necessary so it appears to run the full kamut. I've petitioned the insurer for a copy of the plan documents. I still need to know what code CPT-ORN-1 refers to. If Emory or anyone else has that info, please pass it on.
It is looking more and more from my research that this is all semantics and subject to interpretation and those that push them in the end have a shot at recovering. Ultimately, when this is all over, I may decide to see if we can get some legislative action so that the average Joe, who has enough to worry about, doesn't have to be subjected to this and can just recover some portion of the wig; if purchased as a result of a medical condition and not just for cosmetics.......
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Permalink Reply by Tony on
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Update....
They paid $500 which was the reasonable and customary maximum allowance. For future reference don't give up and don't assume it is not covered. It was initially rejected and paid on appeal.
Use CPT-ORN-1 as the code. No other. Make no reference to the word wig in any letter, bill or document. It is a cranial prosthesis and get the attending physician to indicate the sudden onset of the illness and the medical necessity of the appliance.
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Permalink Reply by Amy on -
I had united once and they weren't too bad. At the time, I just had mild AA, they covered it all. I have anthem now and they cover cranial prtothesis but only like380/year. I submit a rx with that wording and a receipt with that wording. It's a drop in a bucket for a 5k wig but every little bit helps. Don't get me starterted on false eyelash and tattoo costs. This is an expensive disorder.
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Permalink Reply by alwaystipa on
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I don't know if I am correct or not. I'm still researching this one myself.. but I was told the other day that even if your insurance company does not cover the cost of cranial prosthesis you can still write it off as a medical expense on your taxes if you have either a prescription or Letter of Neccesity from your doctor.
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