Provider Cover Letter

Cranial Prosthesis Support Packet · For Medical Providers

To: Treating Provider Name

Date

We are providing this support packet to assist in the evaluation and documentation of patients experiencing medically related hair loss who may qualify for a cranial prosthesis (medical wig).

Hair loss may result from:

Endocrine disorders (e.g., thyroid disease, PCOS, postpartum, menopause)
Autoimmune conditions (e.g., alopecia areata, lupus, lichen planopilaris)
Chemotherapy or radiation therapy
Medication-induced telogen effluvium (SSRIs, anticoagulants, retinoids)
Hormonal imbalance, chronic illness, or stress response

A cranial prosthesis may be considered medically necessary when hair loss results in:

Psychological distress — anxiety, depression, or social withdrawal
Impaired quality of life or self-image
Underlying medical disease requiring ongoing treatment

What We ProvideInsurance-ready documentation · CPT/HCPCS coding support · Fitting & customization · Patient education

Contact Usinfo@crowntexturehair.com
+1 (404) 449-6744
Snellville, GA 30078

Please feel free to refer appropriate patients for evaluation. Our team manages the entire documentation and claims process on your patient's behalf.

Sincerely,

Crown Restore Medical Wig Program

Crown & Texture · Snellville, GA 30078 · info@crowntexturehair.com · crowntexturehair.com/pages/crown-restore-medical-wigs

Cranial Prosthesis Prescription

Complete all fields and email to Crown Restore · info@crowntexturehair.com

Prescribing Physician

Physician Name

Date

Practice / Hospital Name

Specialty

Address

Phone

Fax

NPI Number

DEA Number (if applicable)

State License #

Patient Information

Patient Full Name

Date of Birth

Patient Address

Phone

Insurance Company

Member ID / Policy #

Prescription

Cranial Prosthesis · HCPCS Code: A9282 or S8095 · Quantity: 1 unit per benefit period

Primary ICD-10 Diagnosis Code

Secondary Code (if applicable)

Hair Loss is: Permanent Temporary (treatment-related) Expected duration:

Patient's Natural Hair Texture: Type 1 (Straight) Type 2 (Wavy) Type 3 (Curly) Type 4 (Coily/Kinky)

Letter of Medical Necessity

I certify that the above-named patient requires a cranial prosthesis as a medically necessary treatment for the diagnosed condition. The hair loss significantly impacts the patient's psychological well-being, self-image, and quality of life. This prosthesis is a necessary component of the patient's overall rehabilitative care.

Additional Clinical Notes (optional)

Physician Signature

Sign here with mouse or finger

Date

Clinical Hair Loss Criteria Sheet

For Providers — Check all that apply

Section A — Medical Indications

Endocrine / Hormonal

Hypothyroidism / Hashimoto's thyroiditis Hyperthyroidism / Graves' disease Thyroid medication-induced shedding Polycystic ovary syndrome (PCOS) Postpartum hormonal changes Menopause-related hair thinning

Autoimmune

Alopecia areata Alopecia totalis / universalis Lupus (SLE-related hair loss) Central centrifugal cicatricial alopecia (CCCA) Lichen planopilaris / frontal fibrosing alopecia Traction alopecia Trichotillomania (F63.3) Other autoimmune:

Medication-Induced

Chemotherapy agents (T45.1X5A) Psychiatric medications (SSRIs, mood stabilizers) Blood pressure / cardiac medications Anticoagulants Retinoids or dermatologic medications Other medication:

Stress / Illness-Related

Telogen effluvium — acute or chronic Post-surgical hair loss Severe emotional trauma or hospitalization Chronic illness-related shedding

Section B — Clinical Presentation

Diffuse scalp thinning Patchy hair loss Complete scalp hair loss Eyebrow / eyelash loss Rapid hair shedding (>100–150 hairs/day) Visible scalp exposure affecting appearance

Section C — Functional / Psychological Impact

Anxiety related to appearance Depression or mood changes Social withdrawal Work / occupational distress Reduced self-esteem / body image disturbance

Section D — Medical Necessity Determination

A cranial prosthesis is considered appropriate when all applicable criteria below are met:

Hair loss is due to a documented medical condition Condition is expected to persist >3 months Patient demonstrates psychological distress or functional impairment Alternative treatments are insufficient or ongoing

ICD-10 & Billing Reference

Coding Guide for Insurance Documentation

ICD-10 Diagnosis Codes

ICD-10 Code	Diagnosis Description
L63.0 – L63.9	Alopecia areata (patchy, totalis, universalis, other specified)
L65.9	Non-scarring hair loss, unspecified
L64.9	Androgenic alopecia, unspecified
L65.0	Telogen effluvium
L66.1	Lichen planopilaris / frontal fibrosing alopecia
L66.3	Central centrifugal cicatricial alopecia (CCCA)
L67.8	Traction alopecia
F63.3	Trichotillomania
T45.1X5A	Chemotherapy-induced hair loss (adverse effect, initial encounter)
C80.1	Malignant neoplasm — cancer-related hair loss
E03.9	Hypothyroidism, unspecified
E05.9	Hyperthyroidism, unspecified

CPT / HCPCS Billing Codes

Code	Description	Notes
A9282	Cranial prosthesis (wig), any type	Primary HCPCS code; most widely accepted
S8095	Cranial prosthesis — supplemental	Used by some commercial payers

Both codes may be billed under Durable Medical Equipment (DME). Quantity: 1 unit per benefit period. Prescription must read "Cranial Prosthesis" — never write "wig."

Insurance Coverage Summary

Payer Type	Typical Coverage
Medicare	Accepted — subject to medical necessity documentation and deductible
Medicaid	Accepted — coverage varies by state
BlueCross BlueShield	Accepted — most plans cover partial to full reimbursement
Aetna	Accepted — oncology cases often fully covered
UnitedHealth	Accepted — requires Letter of Medical Necessity
Most major plans	Partial reimbursement: $500–$3,000 depending on plan & diagnosis

Crown Restore handles all of the following on your patient's behalf: Letter of Medical Necessity (LMN) drafting · HCPCS coding (A9282 / S8095) · Claims submission · Insurance follow-up · Patient progress updates to your office

Accepted Insurance Carriers

Medicare Medicaid BlueCross BlueShield Aetna UnitedHealth + Most Major Plans

Patient Referral Flow & Services

Refer Your Patients with Confidence

How to Refer — Step by Step

1

Provider Identifies Hair Loss Condition

Diagnose medically related hair loss and determine ICD-10 code. Confirm patient meets medical necessity criteria (see Criteria Sheet).

2

Complete the Prescription Form

Fill out the Cranial Prosthesis Prescription (page 2 of this packet). Prescription must read "Cranial Prosthesis" — never write "wig."

3

Submit to Crown Restore

Email the completed prescription to info@crowntexturehair.com or fax. Our team will contact the patient within 1 business day.

4

We Handle Insurance Documentation

Crown Restore manages the Letter of Medical Necessity, HCPCS coding, and insurance claims submission on the patient's behalf.

5

Patient Receives Fitting & Customization

Private fitting suite — a dignified, clinical environment. Hair type matched (Types 1A–4C), human hair and synthetic options available.

6

Aftercare & Follow-Up

Styling guidance, maintenance kits, and follow-up appointments provided. Your office receives patient progress updates throughout.

What We Provide Your Patients

Oncology-Certified Fitters

Trained in scalp sensitivity and treatment-phase comfort

Full Texture Library

Types 1A–4C in human hair and synthetic options

Private Fitting Suites

Dignified, clinical environment — not a retail salon

Insurance Navigation

We manage LMN, HCPCS coding (A9282/S8095) and claims

Aftercare Support

Styling guidance, maintenance kits & follow-up care

Patient Progress Updates

We keep your office informed of each referred patient

Phone+1 (404) 449-6744

Emailinfo@crowntexturehair.com

HoursMon–Fri 9am–5pm · Sat by appt