0663T
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record documentation must support the medical necessity of the services as directed in the related LCD (L39573).
- All documentation must be maintained in the patient’s medical record and be available to the contractor upon request.
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
- The submitted CPT/HCPCS code must accurately describe the scalp cooling service performed.
Key Coverage Criteria
- Scalp cooling is used for the prevention of chemotherapy-induced alopecia in patients receiving chemotherapy.
- Use of an FDA-approved scalp hypothermia device for prevention of chemotherapy-induced alopecia is considered reasonable and necessary for patients receiving chemotherapy for solid tumors.
2 Active Policies
A59371 — Billing and Coding: Scalp Cooling for the Prevention of Chemotherapy-Induced Alopecia
L39573 — Scalp Cooling for the Prevention of Chemotherapy-Induced Alopecia
Related Codes
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