AmeriHealth Medical Policies (2025)

Coverage is subject to the terms, conditions, and limitations of the member's contract.

HAIR TRANSPLANTS

When performed as a cosmetic service, hair transplants are a benefit contract exclusion for all products of the Company and are not eligible for reimbursement consideration. However, hair transplants are considered medically necessary and, therefore, covered for the treatment of permanent hair loss that is caused by any of the following conditions:

• Physical trauma (e.g., burns, lacerations)
• Surgery (e.g., tumor removal)
• Diseases that cause cicatricial (scarring) alopecia (e.g., discoid lupus erythematosus, scleroderma)

Hair transplants performed for indications other than those specified in the medical necessity criteria above are considered cosmetic and, therefore, a benefit contract exclusion.

CRANIAL PROSTHESES (WIGS)

Wigs are a standard benefit contract exclusion for most products of the Company. When a benefit exists, wigs are covered and eligible for reimbursement consideration by the Company according to the criteria specified in the group benefit contract. If the group benefit contract does not provide specific criteria for the coverage of wigs, they are covered when all of the following criteria are met:

• The member's purchased group benefit includes coverage of wigs, and the service is provided within the scope of the member's benefit contract.
• The wig has been ordered by a professional provider.
• Significant hair loss exists, with a projected duration of at least six months, due to a condition or injury such as, but not limited to:
  • Alopecia universalis/alopecia totalis
  • Alopecia areata
  • Burns
  • Chemotherapy/radiation therapy
  • Traumatic or surgical scalp avulsions

The Company does not provide benefits for wigs or other items that are intended to replace hair loss associated with either of the following:

• Male-pattern baldness/female-pattern hair loss
• Cosmetic purposes

When a benefit exists, coverage limitations for wigs, repair and replacement, and dollar amount related to lifetime and/or annual maximums vary by product or by group; therefore, individual member benefits must be verified.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for hair transplants require review by the Company and must include color photographs and a letter of medical necessity from the provider.

BENEFIT APPLICATION

HAIR TRANSPLANT
Subject to the terms and conditions of the applicable benefit contract, hair transplants are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

CRANIAL PROSTHESES (WIGS)
Subject to the terms and conditions of the applicable benefit contract, wigs are a standard benefit contract exclusion for all products of the Company except Major Medical. However, when purchased as a group benefit, wigs are covered under the medical benefits of the Company's products. Individual benefits must be verified.

Alopecia (hair loss) can be caused by aging, hormonal changes, genetic predisposition, or circumstances such as disease or physical trauma. In most disorders of alopecia, the hair follicle is either normal but has an abnormal growth cycle, or it has been damaged. Hair transplants and cranial prostheses (wigs) are frequently used to treat hair loss.

COMMON TYPES OF ALOPECIA

ANAGEN EFFLUVIUM
Anagen effluvium is abnormal diffuse hair loss arising during the growth stage of the hair cycle that may leave the scalp partially or completely bald. The condition begins days to weeks after exposure to a chemotherapeutic agent. It is most apparent after one or two months after chemotherapy administration and is usually reversible with hair regrowth after cessation of the chemotherapeutic agent.

ANDROGENIC ALOPECIA
Androgenic alopecia is known as male-pattern baldness in men and female-pattern hair loss in women. It is the most common form of alopecia that results in permanent hair loss. Hair loss is mediated by a combination of genetic factors and levels of testosterone.

ALOPECIA AREATA
Alopecia areata is an autoimmune disease that is characterized by a localized area of complete hair loss that is usually in coin-shaped patches on the face, scalp or other areas of the body that normally grow hair. Thyroid abnormalities and pernicious anemia are frequently the underlying factors of alopecia areata. Alopecia areata encompasses the following types:

• Patchy alopecia is circumscribed, oval shaped, flesh colored patches on any part of the body.
• Alopecia totalis involves the entire scalp.
• Alopecia universalis results in hair loss across the entire scalp, face (including eyebrows and eyelashes), plus the rest of the body (including pubic hair).
• Diffuse alopecia areata results in sudden and unexpected thinning of the hair all over the scalp.
• Ophiasis alopecia involves a unique pattern of hair loss which includes the sides and lower back of the scalp, called the occipital region, in the shape of a band.

TELOGEN EFFLUVIUM
Telogen effluvium is a form of hair loss characterized by hair thinning or an increase in hair shedding that arises during the resting stage of the hair cycle especially on the top of the scalp that usually happens after stress, a shock or traumatic event. It is a reactive process occurring more often in women, that resolves spontaneously when the underlying cause is eliminated. A list of inciting factors includes severe, chronic illnesses, pregnancy, high fever, malnutrition, endocrine disorders, severe infections, and emotional and physiologic stress.

CICATRICIAL (SCARRING) ALOPECIA
Cicatricial alopecia refers to a collection of rare hair loss disorders (e.g. folliculitis decalvans, pseudopelade) that result from a condition, such as an infection (e.g., herpes zoster), autoimmune disease (e.g., discoid lupus erythematosus), sarcoidosis, scalp trauma (e.g., burns), or radiation therapy, that destroys the hair follicle without regrowth, and replaces it with scar tissue, causing permanent hair loss.

TRAUMATIC ALOPECIA
Traumatic alopecia is caused by cosmetic practices that damage hair follicles over time and has been linked to the use of brush rollers, curling irons, tight braiding and repetitive exposure to harsh hair chemicals or disorders such as trichotillomania (compulsive behavior involving the repeated plucking of hair).

HAIR TRANSPLANTS

Hair transplants involve transferring hair follicles from one body site to another for the treatment of conditions such as, but not limited to, alopecia or physical trauma.

There are several types of hair transplant techniques, which include but are not limited to: strip grafts (30 to 40 hairs), punch grafts (10 to 15 hairs), mini-grafts (three or six hairs), and micrografts (one or two hairs).

CRANIAL PROSTHESES (WIGS)

A cranial prosthesis (wig) is a manufactured covering for the head that is made of natural or synthetic hair. The term "wig" also applies to hairpieces and similar manufactured coverings that are used to replace or supplement hair.

COSMETIC SERVICES

Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement does not constitute improvement in physiologic function.

MEDICALLY NECESSARY

A9282 Wig any type, each

Revisions From 11.08.01f:

Effective 10/05/2017 this policy has been updated to the new policy template format.