Paxman announces that the Palmetto GBA Medicare Administrative Contractor (MAC) has issued a Local Coverage Determination (LCD) to provide coverage determination for scalp cooling for the prevention of chemotherapy-induced alopecia. According to the Palmetto GBA final LCD guidance, “the use of a scalp hypothermia device, which has been approved by the United States (US) Food and Drug Administration (FDA) for the prevention of chemotherapy-induced alopecia (CIA), should be considered reasonable and necessary in patients with solid tumors.” Additionally, no changes were made between the proposed LCD and the final LCD.
This is the first LCD to be approved for scalp cooling and is the result of a request from Paxman to the Palmetto GBA in February 2023. This important Palmetto LCD provides a pathway for successful reimbursement of Medicare scalp cooling requirements for patients in the seven-state service area, effective November 12, 2023. PAXMAN currently serves 55 locations within the Palmetto GBA jurisdiction.
A MAC is a private health insurance company that has been assigned a geographic jurisdiction to process claims for Medicare beneficiaries. Palmetto GBA serves two jurisdictions in the US Medicare system covering seven states in the southern United States: Alabama, Georgia, North Carolina, South Carolina, Tennessee, Virginia and West Virginia.
CMS tasks MACs with developing LCDs to describe reasonable and necessary services within the Medicare program. CMS also tasks MACs with developing coverage articles that provide guidance on how to bill or code for a service or provide training on a specific topic. In Billing and Coding Guide: Scalp Cooling for the Prevention of Chemotherapy-Induced Alopecia, Palmetto GBA confirms the guidance from CMS, "CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, §110.6 scalp hypothermia during chemotherapy to prevent hair loss is not a barrier to coverage or for pricing/payment of Category III Temporary CPT® codes for professional/facility services related to scalp cooling (CPT® codes 0662T and 0663T)."
This action further strengthens local coverage and promotes support for healthcare providers to receive reimbursement from Medicare for administering FDA-approved scalp cooling therapy, such as Paxman Scalp Cooling. Two separate CPT® Category III codes for “mechanical scalp cooling,” 0662T and 0663T, were issued by the AMA with an effective date of July 1, 2021. The CPT® codes, along with coverage determinations like this approved LCD, will expand patient access to scalp cooling and do enable oncology providers to appropriately offer the service and bill for the resources required to administer scalp cooling therapy.
Paxman will use the approval of this LCD to shape the strategy with other MACS around the country.