Does Insurance Cover Cranial Prostheses? What You Need to Know

Cranial prostheses can be expensive, so many people ask: Does insurance cover cranial prostheses?

The answer is: sometimes. Insurance coverage depends on your health insurance plan, the reason for your hair loss, how the cranial prosthesis is classified under your policy, and the rules that apply where you live.

Some insurance plans may provide coverage when the cranial prosthesis is considered medically necessary. Other plans may exclude wigs, hairpieces, or cranial prostheses as cosmetic items.

Here is what you should know before buying a cranial prosthesis:

Does Health Insurance Cover a Medical Wig?

Some private health insurance plans may cover a cranial prosthesis when it is considered medically necessary. However, other plans may specifically exclude wigs or hair replacement products.

Your policy may also have specific requirements before you can receive reimbursement. For example, an insurer may require:

• A diagnosis of a medical condition causing hair loss
• A prescription from a doctor
• Documentation showing medical necessity
• An itemized receipt from the supplier
• A specific billing or procedure code
• Prior authorization
• Purchase from an approved provider
• A claim submitted within a specific period

This is why it is important to check your individual policy instead of assuming that your insurance will or will not pay. Insurance rules can also differ depending on where you live. 

In the United States, for example, the National Association of Insurance Commissioners (NAIC) lists state laws involving coverage for scalp hair prostheses. Some states have laws requiring certain health plans to provide coverage for specific types of medically related hair loss. 

When is a Cranial Prosthesis More Likely to be Covered?

Coverage is generally more likely when hair loss is connected to a documented medical condition or treatment. Some situations that may be relevant include:

1. Cancer Treatment

Chemotherapy and some other cancer treatments can cause significant hair loss. Some insurance policies may provide benefits for braided wigs or scalp prostheses associated with cancer treatment. However, coverage depends on the specific insurance policy and applicable laws.

For example, the NAIC's compilation of state insurance laws identifies states where certain plans are required to cover scalp hair prostheses for hair loss associated with cancer treatment. 

2. Alopecia

Alopecia refers to hair loss that can occur for several different reasons. Certain types, including alopecia areata and alopecia totalis, may be addressed by insurance laws or individual health plans.

For example, the NAIC identifies Minnesota as having a law requiring certain accident and health insurance policies to cover scalp hair prostheses for hair loss caused by alopecia areata.  This does not mean every person with alopecia automatically qualifies for coverage. The exact policy and eligibility requirements still matter.

3. Hair Loss From Injury or Surgery

Some policies may provide coverage when permanent scalp hair loss results from an injury or medical procedure. The circumstances surrounding the hair loss can therefore make a difference when an insurance company evaluates a claim.

How to Find Out if Your Insurance Covers a Cranial Prosthesis

Before purchasing your cranial prosthesis, take these steps.

1. Read Your Insurance Policy

Look through your policy or benefits booklet for terms such as:

• Wig
• Hair prosthesis
• Scalp prosthesis
• Cranial prosthesis
• Prosthetic device
• Medical necessity
• Alopecia
• Hair loss
• Durable medical equipment

The word may differ from one insurance company to another.

2. Call Your Insurance Provider

Call the member services number on your insurance card. Ask a question like: “Does my plan cover medical braided wigs or cranial prosthesis?” Also ask whether you need prior authorization.

3. Ask Your Doctor for Documentation

If your insurance requires medical documentation, your doctor may need to provide information about your diagnosis and the reason the cranial prosthesis is medically necessary. A prescription may also be required.

4. Ask About Your Out of Pocket Cost

Even if your plan covers the prosthesis, you may still have a deductible, copayment, coinsurance, reimbursement limit, or annual benefit limit. Ask how much you will have to pay yourself.

5. Ask About Approved Suppliers

Some insurance plans require you to purchase medical products from specific providers. If you buy from a supplier outside your plan's network, you may receive less reimbursement or no reimbursement at all.

What if Your Claim is Denied?

This does not mean the process is over. Start by finding out why the insurance company denied your claim. The insurer may say that the product is excluded, that medical necessity was not established, that documentation was missing, or that the supplier was not eligible.

Ask the insurance company about its appeal process if you believe the claim should be covered. You may need to provide additional documentation from your doctor or other healthcare provider. Keep copies of your prescription, medical records related to the hair loss, receipts, correspondence, and claim documents.

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Conclusion

So, does insurance cover cranial prostheses? In some cases, yes, but coverage is not automatic.

The most important factors include the cause of your hair loss, your insurance policy, medical necessity requirements, documentation, and the laws that apply to your coverage. Some U.S. state laws specifically address coverage for scalp hair prostheses in certain circumstances, while individual plans may have their own requirements. 

Before purchasing a cranial prosthesis, contact your insurance provider, ask about coverage and reimbursement, check whether you need a prescription, and find out whether you must use an approved supplier. These can help you avoid unexpected expenses.

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