Billing & REIMBURSEMENT

Scalp Cooling Access and
Reimbursement with Paxman

Insurance reimbursement is now available for scalp cooling through the Paxman Buy & Bill model, which allows facilities to bill insurance providing greater access to scalp cooling for their patients.

We are here to help with reimbursement support to ensure the best outcome for you and your patients. View all of our supportive information and downloads below.

Downloads & Resources

Claim Filing Assistance

As a part of the Buy and Bill model, the Paxman Hub are here to help with the insurance coverage process and paperwork.

Benefits Investigation Process

The Paxman Hub will conduct a Benefits Investigation to determine a patient's health insurance coverage. After verifying coverage, we will provide:

  • The Benefits Investigation outcome results to the provider, via a Summary of Benefits (SOB)
  • The results of the SOB are shared by the clinical team with the patient
  • If the Benefits Investigation confirms the patient is under or uninsured, the Hub will assess the patient for the Paxman Patient Assistance Program

Prior Authorisation (PA) Assistance

If a PA is required following the SOB, the Paxman Hub will coordinate with a patient’s insurer to determine the Prior Authorization (PA) requirements. The provider will need to submit the PA, however, the Paxman Hub will support by sharing whether a PA is required, where and how to submit requests, and typical turnaround times. Following the submission of the PA request, the Hub will follow up with the insurer to track the progress and status on behalf of the patient.

The Hub will then communicate to the provider if the PA is approved, or assist through one appeal if the PA is denied.

Downloads are available below of the sample templates and checklists that may be helpful in cases where additional information is required by the insurer.

Sample Letter of Medical Necessity
Claim Filing Checklist
Prior Authorisation Checklist

Appeals Assistance

In cases where a PA has been denied, the Paxman Hub can review the reasons for a denied claim and help with the appeals process by providing information on payer requirements.

Downloads are available below of the sample templates and checklists that may be helpful in cases where additional information is required.

Sample Letter of Appeal
Letter of Appeal Checklist

Paxman Patient Assistance Program (PAP)

If your patient is unable to obtain insurance coverage for scalp cooling, the Paxman Hub will determine if they qualify for our Patient Assistance Program.*

*Please note: The PAP is only available to facilities who are contracted under Paxman’s buy and bill business model.

Patient Assistance Program (PAP)

If patients qualify for the PAP they will receive a cap kit free of charge from their provider, and the Paxman Hub will send a replacement cap kit to the provider. The provider will not charge the patient for the cap kit or any scalp cooling treatments.

The Paxman PAP assists patients who:

  • Are uninsured or underinsured for scalp cooling
  • Reside in the US and have a physical US address
  • Have an on-label diagnosis
  • Have a valid prescription for scalp cooling from a licensed prescriber
  • Have a household income of 6x US Federal Poverty Level or below

 

Automatic Qualification
into the PAP

If EITHER of these criteria are met, a patient will automatically qualify into the Paxman PAP:

Patient has an adjusted gross income of less than or equal to 600% of the Federal Poverty Level based on HHS

Hardship waiver available if product if >50% of household income

Conditional Qualification
into the PAP

Patient has no health insurance

Patient must have no/not enough coverage (uninsured or underinsured patients)

Patient has insurance but scalp cooling not covered

PA denied with no appeal available or first appeal denied

Billing and Coding Information

For claim submissions on behalf of your patients, we provide scalp cooling billing and coding information for your physician’s office and hospital outpatient settings of care.*

Scalp Cooling CPT Codes

In the physician’s office and hospital outpatient department sites of care, Medicare Administrative Contractors (MACs), private commercial payers, and Medicaid may recognize the following codes for scalp cooling based on AMA CPT Editorial Panel’s recent coding update.1

CPT Code

0662T

0663T

Descriptor

Scalp cooling mechanical; initial measurement and calibration of cap. This code is billed when the cap is fitted to the patient and may only be utilized one time per patient.

Placement of device, monitoring, and removal of device. This code is billed each time the patient receives scalp cooling during chemotherapy and is to be used in conjunction with chemotherapy administration codes 96409, 96411, 96413, 96415, 96416, and 96417.

ICD-10-CM Diagnosis Codes

The Paxman Scalp Cooling System is indicated to reduce the likelihood of chemotherapy-induced alopecia (CIA) in cancer patients with solid tumors. Trials were conducted on patients who had solid tumors, such as ovarian, breast, colorectal and prostate cancers.

All diagnosis codes should correspond accurately to the patient’s condition and at full discretion of the patient’s physician.

 

For additional information on coding, procurement and billing information, download the guide below.

Scalp Cooling Procurement & Billing Guide

1HOPPS Final Rule, November, 2021: 2021-24011.pdf (federalregister.gov)

*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 requirements, practice patients, and the services rendered.

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