Patterns of insurance coverage for wigs in patients with alopecia areata: a cross-sectional survey

What is known about this subject with respect to women and their families?

• Alopecia areata is an autoimmune form of nonscarring hair loss that disproportionately affects women.
• Hair is an important aspect of self-image and hair loss can lead to adverse psychological consequences.
• Wigs, or cranial prostheses (CP), help minimize the stigmatization of hair loss and improves patients’ confidence and quality of life. However, the most common limitation to obtaining a wig is cost.

What is new in this article with respect to women and their families?

• Insurance coverage for CP is insufficient and further adds to the financial and psychological burden on patients with alopecia areata: the average cost of CP was $1,543 and insurance coverage ranged from $50 to the full cost of the CP.
• There was little awareness of insurance coverage among participants as an option to offset CP costs.

Dear Editors,

Alopecia areata (AA) is an autoimmune form of nonscarring hair loss. Currently, patients on Medicare and Medicaid cannot receive insurance coverage for wigs, or cranial hair prostheses (CP). On September 30, 2021, Representative James McGovern proposed an amendment to title XVIII of the Social Security Act to provide coverage for CP as durable medical equipment under the Medicare program, and for other purposes.¹ CP have been shown to improve the quality of life in patients with AA, but the most common limitation to obtaining a CP is its price.² No studies have examined insurance coverage patterns for patients with hair loss. Therefore, we conducted a survey examining the out-of-pocket costs and insurance coverage for CP in patients with AA.

This study was exempt by the Lahey Hospital & Medical Center institutional review board. A web-based survey was distributed to National Alopecia Areata Foundation members in July 2022 via email.

A total of 931 individuals accessed the survey and 626 individuals completed it (response rate: 67%). Participants were mostly Caucasian (73.1%), female (92.1%), average age of 50.1 ± 17.9, and 475 (75.7%) reported having ≥50% scalp hair loss (Table 1). Almost all participants considered getting a CP or other hair piece (93.1%). Most participants did acquire a CP (85.7%). The total cost of CP in US dollars was $654,597 with an average cost of $1,543 ± $3,747. Some participants (38.2%) sought out insurance coverage and only 23% of those participants received it. Coverage ranged from $50 to the full cost of the CP. Most participants believed that their insurance coverage was inadequate (65.9%).

Table 1 - Demographics, patient insurance coverage satisfaction, alopecia areata, CP, and insurance coverage characteristics

Item	Mean (SD)
Age	50.1 (17.9)
Race, ethnicity, or origin	n (%)
White	458 (73.1)
Hispanic, Latino, or Spanish origin	43 (6.8)
Black or African American	103 (15.4)
Native Hawaiian or other Pacific Islander	4 (0.6)
Asian	23 (3.6)
American Indian or Alaska Native	8 (1.2)
Middle Eastern or North African	8 (1.2)
Other race, ethnicity, or origin	7 (1.1)
Gender/gender identity	n (%)
Woman	577 (92.1)
Man	47 (7.5)
Trans man	0 (0.0)
Trans woman	0 (0.0)
Nonbinary	1 (0.2)
Chose not to disclose	1 (0.2)
Percentage of the scalp affected by alopecia areata	n (%)
≤20%	59 (9.4)
21% to 50%	92 (14.6)
>50%	475 (75.7)
Considered getting CP or other hair piece	n (%)
Yes	583 (93.1)
No	43 (6.8)
Got a CP or other hair piece	n (%)
Yes	500 (85.7)
No	83 (14.2)
Sought out insurance coverage for CP or other hair piece	n (%)
Yes	191 (38.2)
No	309 (61.8)
Received insurance coverage for CP or other hair piece	n (%)
Yes	44 (23.0)
No	147 (76.9)
Item	Mean (SD)
Cost of CP in US dollars	1,543 (3,747)
Insurance coverage amount in US dollars	685 (639)
Satisfaction with insurance coverage	n (%)
Very inadequate	18 (40.9)
Inadequate	11 (25.0)
Neutral	4 (9.0)
Adequate	7 (15.9)
Very adequate	4 (9.0)

CP, cranial hair prostheses.

We report that insurance coverage for CP is insufficient and further adds to the financial and psychological burden on patients with AA (Table 2).^3,4 In addition, there was little awareness of insurance coverage among participants as an option to offset CP costs.

Table 2 - Free responses from survey participants highlighting financial burden and thoughts on insurance coverage for CP

My doctor even wrote me a letter saying I have a cranial prosthetic and as soon as they heard the word wig they wouldn’t help with coverage.
It didn’t occur to me that insurance might cover the cost of a wig, but I would appreciate it.
I’m on Medicare, and prosthetic hair pieces are not covered, not in the almost 10 years I have had Medicare. I’ve been wearing wigs since 1978. I cannot afford my usual wig anymore, so I’ve had to get a $100 wig which is not the quality I’ve been wearing. It makes me sad that insurance companies can’t cover at least part of the cost of wigs.
I have dealt with this all my life. I miss out on a lot of things because I can’t always afford a wig. So I just stay home.
Wigs are covered by insurance for cancer patients. Why would wigs not be covered for people with Alopecia Areata? It isn’t fair to exclude people with an autoimmune disease.
I have been wearing wigs for 23 years due to alopecia, and insurance has continuously denied coverage. My doctors have even written prescriptions for a “scalp prosthetic” to alleviate depression caused by my hair loss, but insurance still denied coverage. I spend on average $1,500 per year on wigs.
When I looked at insurance coverage it says it’s for cancer-related hair loss so I never bothered trying.
I only feel confident while wearing a hair system in public. This is a major non-reimbursed expense that I feel is medically necessary.
Alopecia is always considered a cosmetic issue but losing your hair, eyebrows, and eyelashes is more than a cosmetic issue. Our hair serves a purpose on our bodies. My alopecia has also caused self-esteem issues, depression, and anxiety. I wish insurance providers covered more to treat alopecia
I have had Alopecia Universalis for 16 years, however now with eyelash growth I am Totalis. All these years I have had no help with insurance. Wigs made of real hair are expensive, generally 1400 plus. Just recently, I had to apply for a credit card with high interest just to buy one.
I am African American, and typically have a hard time finding a realistic wig or hair piece that looks natural that will stay in without having to use toxic glues to keep it securely in place or spending hundreds of dollars. It would be amazing to find something cute and natural, that will stay securely in place and isn’t too expensive or is covered by my insurance plan.

CP, cranial hair prostheses.

There is an absence of consistency in coverage for CP between states. In the state of Massachusetts, all insurance companies are required to cover CP at a $350 annual maximum for hair loss due to cancer or leukemia only.⁵ The treating physician must state in writing that the CP is medically necessary if the insurance company covers hair loss due to other conditions (eg, AA). Contrarily, all insurance companies in the state of Minnesota are required to provide coverage for CP at a $350 annual maximum for hair loss specifically due to AA.⁵ While certainly a step in the right direction, this $350 reimbursement still leaves AA patients with a significant cost burden. Given Medicare’s immense influence over coverage in the private sector, the passing of this bill to amend the Social Security Act will undoubtedly have a large impact on smaller insurance companies nationwide. We hope that the results of our study can encourage awareness among physicians and insurance companies regarding the treatment costs of CP in patients with hair loss.

Conflicts of interest

None.

Funding

None.

Study approval

N/A

Author contributions

OE, SD, AL, and MS: Participated in research design, writing, and data analysis. KJK: Participated in research design. LA and NF: Participated in writing.