INSURANCE COVERAGE AND REIMBURSEMENT
Although insurance coverage for scalp cooling is not yet standard in the United States, DigniCap patients have submitted insurance claims and received reimbursement for treatment costs at varying levels since DigniCap received FDA clearance in 2015.
As of July 2021, two new CPT codes for scalp cooling providers will go into effect, however, this type of code may only be used by providers who bill patients for DigniCap treatment. The new CPT codes are not valid for patients whose facilities have them purchase DigniCap kits and treatment cards directly from Dignitana.
CPT codes do not guarantee coverage. Success with reimbursement varies depending on plan, coverage, and location.
Our Patient Support Team is here to help as you navigate the reimbursement process with your insurance company. Please contact the Patient Support Center and a reimbursement specialist will get in touch with you.
When submitting an insurance claim:
- Call your insurance provider to check benefits and obtain a blank claim form. It may be beneficial to ask your provider if they require preauthorization for scalp cooling treatments.
- The ICD-10-CM diagnosis code on the claim form needs to match the diagnosis in your medical record exactly. The primary diagnosis code will likely be in the range of:
– C50-C56 (Malignant neoplasm of breast or female organs)
– 0-C96.9 (Malignant neoplasm)
- Suggested secondary diagnosis codes:
– Z51.11 (Encounter for antineoplastic chemotherapy)
– L65.9 (Nonscarring hair loss unspecified)
- For patients filing for reimbursement of DigniCap, 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:
- NCCN Clinical Practice Guidelines in Oncology 2019 and 2020 list scalp cooling as a Category 2A recommendation to reduce the incidence of chemotherapy-induced alopecia for patients receiving chemotherapy.
- ONS Guidelines™ for Cancer Treatment-related Skin Toxicity 2020 recommends scalp cooling
- Journal of the American Medical Association (JAMA) published scalp cooling study
- Oncology Research and Treatment published study on scalp cooling
- Include a Letter of Medical Necessity from your doctor. – download sample letter
- DigniCap FDA clearance letter – download letter here
- Ask your doctor’s office for progress notes that reference that you are using scalp cooling.
- Ask your doctor for an MD Order or prescription for scalp cooling.
- Include receipt of payment for scalp cooling treatment.
Dignitana is a Third-party Out-of-Network provider, and has no formal agreement with any Third-Party Payer (insurance company). Dignitana 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.
Note that Dignitana does not have an NPI (National Provider Identification) number. If your insurance provider requests Dignitana’s Tax ID number, contact the Patient Support Center.
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 affect 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.
Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA) can often be used to pay for medical expenses not covered by insurance. Contact your provider to assess if you can apply funds to your scalp cooling therapy.
Please share your experience regarding scalp cooling and insurance by taking the survey at scalpcoolingsurvey.com
For information on organizations offering patient assistance to scalp cooling patients CLICK HERE.
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