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INDEX:
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Effective Date: 09/18/1995 Title: Alopecia
Revision Date: 05/12/2010 Document: BI172:00
CPT Code(s): 704.x, 15775, 15776
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Alopecia is the partial or complete loss of hair.  The cause of hair loss is often indicated by the way it falls out and the condition of the scalp.  Loss of hair may be the result of the aging process, hereditary factors, certain skin diseases, drugs, radiation, or certain systemic diseases.  The most common types are:

  • Male pattern baldness typically begins in the frontal area and proceeds until only a horseshoe of hair remains in the back and temples. It is a result of a hereditary predisposition and testosterone (male sex hormone). It may happen in women as well as men. The treatment of male pattern baldness is not covered.
  • Female pattern baldness is a general thinning of hair at the crown or hairline. It seems to have the same hereditary component as male pattern baldness, but without the testosterone. The treatment of female pattern baldness is not covered.
  • Alopecia areata may manifest as a single area of hair loss or as a number of patchy areas of hair loss. It is usually due either to a local skin condition or to a systemic disease. The evaluation and medical treatment of alopecia areata is covered. Hair transplantation for chronic hair loss is not a covered service.
  • Telogen effluvium is usually temporary (3-4 months) and generally follows a severe illness or stress. During the illness or stress, a large number of hair follicles all go into resting phase at the same time. When the hairs begin to grow out again, the old hairs fall out, creating a sudden loss of hair. No treatment is required as the hair is already growing back in by the time the old hairs fall out.

When alopecia is caused by a systemic illness or by a skin disease of the scalp, the treatment of that illness is covered. The treatment of alopecia that is cosmetic (male or female pattern baldness) is not covered. In no case will drugs designed to grow more hair (whether taken by mouth or applied to the scalp), prosthetics, or surgical transplantation be covered. 


Medical Statement

The treatment of hair loss is generally a cosmetic problem, not a medical one; however, making the appropriate diagnosis is a matter of some significance. Therefore, QualChoice will continue to cover all visits to a PCP with any diagnosis related to hair loss. This will assure the patient access to have a presumptive diagnosis made.

Treatment of male or female pattern baldness with topical or systemic medications is not covered – the prescriptions for those medications will be denied for payment. Hair transplants are also not covered.

Treatment of medication-induced baldness is also not covered.

In the case of hair loss caused by a systemic illness, coverage will be provided for the treatment of the causative illness. Local treatment to ameliorate the hair loss will not be covered.

In the case that the hair loss is caused by a disease of the scalp which results in hair loss, treatment of the underlying dermatologic problem, including consultation with a dermatologist, will be covered. Local treatment specifically directed at the restoration of hair growth will not be covered.

Codes Used In This BI:

704.x

15775           Hair transplant punch grafts

15776           Hair transplant punch grafts


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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