FINDING A DOCTOR
Treatment options are best discussed with the doctor who made the diagnosis or other qualified medical professional. Your healthcare provider is likely to be your best source of medical information.
If you are unable to find a health care provider in your area who treats patients with alopecia areata, please contact the NAAF office by phone or email. NAAF keeps a list of doctors across the US who treat alopecia areata patients.
Obtaining insurance coverage for the medical treatments for alopecia areata can present a challenge since no treatments are currently approved by the FDA for this disease, and so any treatment is “off-label” (used in a way that is not listed on the drug label). The reimbursement problem is compounded by the insurance industry often perceiving such treatments as merely “cosmetic”, rather than medically necessary, and using this description to deny claims.
Hopefully, once medicines are identified that may effectively reverse alopecia areata, companies will engage in randomized, placebo controlled clinical trials for these treatments in alopecia areata patients and request FDA approval for those that demonstrate positive outcomes. In the meantime, however, this often leaves the alopecia areata patient scrambling for insurance reimbursement for “off-label” treatments.
Tips on Applying for Insurance Reimbursement
1. Know your insurance policy and what it covers.
- Diagnosis is billed using the International Classification of Diseases (ICD) coding system. The latest version (ICD-10) diagnostic codes for alopecia areata are from L63.0 to L63.9 depending on the type of alopecia areata. In the ICD-9 version, there was only one code of 704.01 for all types of alopecia areata.
- For wig reimbursement, Healthcare Common Procedure Coding System (HCPCS), administered by the Centers for Medicare and Medicaid Services (CMS) in cooperation with other third party payers, are used to report supplies, equipment, and devices provided to patients. The HCPCS billing codes for wigs are S8095 and A9282.
- Investigate how your policy handles a specific treatment and whether prior authorization is needed for a therapy.
- Understand any copays and how much you will be expected to contribute to the cost of a therapy.
- Know whether your insurance company requires “step therapy,” which means you must try and fail one therapy before the next level of therapy can be covered.
2. Do your homework before submitting a claim.
- Some treatments require preauthorization. Be aware whether this is the case with your therapy.
3. Make sure your medical records are accurate.
- Maintain copies of your medical records. You have the right to receive copies of all of your medical records. Note that you can be charged a copy fee.
4. Include a Letter of Medical Necessity. Contact NAAF for a sample letter.
5. Always appeal denials!
- Denials for alopecia areata patients most often are attributed to the insurance company designating a therapy as cosmetic, not medically necessary, and/or being experimental or investigational in alopecia areata and prescribed as off-label use. Statistically, about 40% of appeals are successful, so NAAF urges you to always appeal a denial at every level.
- Prepare for Denial of Your Claim.
- Involve your doctor in helping you respond to a denial.
- Documentation is crucial! In addition to making sure you have the necessary documentation showing that your case meets the insurance provider’s guidelines and demonstrates medical need, maintain records of your communication with the insurance company. Document every time you speak or hear from a company representative; Record the person’s name, date, time and key messages from the conversation.
- Familiarize yourself with your insurance company’s guidelines and deadlines for appeal. This information is usually included in the denial letter.
- Understand why you were denied, so you can address the insurance company’s reason(s) directly.
- If you are communicating with the Customer Service office of the insurance company and are dissatisfied with the response, ask for a Nurse Case Manager or a Supervisor who might be more understanding of your situation.
- If you did not previously include a Letter of Medical Necessity, make sure you include one for the appeals process.
- When possible, demonstrate that a treatment results in clinically meaningful improvement in quality of life to justify costs.
- If you are still denied following the final round of appeals for a treatment, contact the advocacy or patient assistance program for the company that produces the treatment. Most companies have divisions that take applications for financial assistance for their therapies.
- If you are unsuccessful with the appeal process, consider contacting your state insurance commission. You can find them here: www.naic.org/state_web_map.htm.
How to Draft an Appeal Letter
Include the following information and documentation:
- Your policy and claim numbers, employer name if your policy is through an employer, and the full name of the insured
- The therapy or procedure for which you were denied and why the denial letter stated you were denied
- Medical records that back up your diagnosis and medical problem that relates to the therapy in question
- Letter of Medical Necessity
- If the Letter of Medical Necessity is not signed by your physician, have your physician provide a letter of support that includes the reason for recommending or prescribing your therapy.
- Two or more articles from respected medical journals backing your claim of medical necessity
- Refer to the NAAF website as an authoritative source of medical information on alopecia areata.