Forms & RESOURCES

Scalp Cooling Reimbursement

Download these forms and resources for processing claims and submitting prior authorizations and appeals.

The following forms are only relevant for sites that have a Buy & Bill contract with Paxman.

Sample Letters & Checklists*

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 & Coding Information*

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.

© Paxman Coolers 2022