Sample Letter of Medical Necessity
Claim Filing Checklist
Prior Authorization Checklist
Sample Letter of Appeal
Letter of Appeal Checklist
*The information contained a these template letters is provided by Paxman for informational purposes for patients prescribed scalp cooling.
These templates are not intended to substitute for a prescriber’s independent medical decision-making.
Billing & Procurement Guide
*The information provided here is intended for informational purposes only and is not a comprehensive description of potential coding requirements for scalp cooling. Coding and coverage policies change periodically and often without warning. The healthcare provider is solely responsible for determining coverage and reimbursement parameters and accurate and appropriate coding for treatment of his/her own patients. The information provided in this section should not be considered a guarantee of coverage or reimbursement for scalp cooling.
The sample forms are intended as a reference for billing and coding of scalp cooling. These forms are not intended to be directive or to replace clinical decision-making, and the use of the recommended codes does not guarantee reimbursement. Healthcare providers may deem other codes or policies more appropriate and should select the coding options that most accurately reflect their internal guidelines, payer requirements, practice patients, and the services rendered.
