Universal scalp cooling access billed through insurance
US scalp cooling access & support
Since scalp cooling achieved FDA clearance in 2017 and was subsequently included within the NCCN guidelines, Paxman’s vision has always been to ensure equitable access to the treatment for all. Everyone should be able to feel like themselves.
Bill for scalp cooling through insurance
Paxman Scalp Cooling is available throughout the United States, covered under Category I CPT® codes (commonly known as buy and bill) when administered by trained clinical staff under the supervision of a qualified healthcare professional and in an office or facility setting.
Benefits of Insurance Billing
Equitable access reduces financial burden by unlocking insurance coverage and generous assistance
Increase scalp cooling access for patients
Recognizing site of care for staff and chair time involved in scalp cooling
Reduce the financial burden of cancer diagnosis
Increased access drives patient demand
Remain confident with Paxman support for under or uninsured patients
Secure fair, reimbursable workflows
Category I CPT® Codes
Effective January 1, 2026
97007
Scalp cooling, mechanical; initial measurement and calibration of cap.
Report once prior to infusion
97008
Mechanical scalp cooling; including hair preparation, individual cap placement, therapy initiation, and precooling period.
Report once per chemotherapy session
97009
Provided after discontinuation of chemotherapy, each 30 minutes (list separately in addition to code for primary procedure).
Report once per chemotherapy session
Sites across the United States are experiencing successful reimbursement under these codes through both Medicare and a number of Commercial Payers.
We provide structured implementation support to help you do the same.
The Paxman Patient Assistance Program
What happens in the event where a patient is underinsured or uninsured?
This is where the Paxman’s generous Patient Assistance Program (PAP) comes in. This acts as a safety net, catching anyone who meets the eligibility criteria.
The Paxman Patient Assistance Program* assists patients who:
Are uninsured or underinsured for scalp cooling
Reside in the US and have a physical 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
Patients at or below 600% of the federal poverty level receive a cap kit free-of-charge if they are uninsured or underinsured. A free-of-charge replacement cap kit will be provided by Paxman.
* The PAP is only available to facilities who are contracted under Paxman’s Insurance-Based Billing Model.
Conditional qualification into the Patient Assistance Program
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
90%
For the period June 2022 to January 2025, 90% of patients did not pay out-of-pocket due to positive coverage or support from the Paxman Patient Assistance Program.
FAQs
Do you have any recommendations or guidance on appropriate fee ranges associated with these codes?
Most facilities have a specific formula to determine how much to charge for codes. If a facility wishes to be paid $100, it will often submit a claim to insurance for $300$400.
Despite the PAP Program, we still struggle with access due to the current per treatment fee. What would you advise?
Coverage is evolving and is expected to grow with Category I CPT codes in place as of January 1, 2026.
Has New York (after passing the insurance bill) seen a drastic increase in patients using Paxman? Have facilities had to increase their number of Paxman machines?
New York has always had a significant number of scalp cooling providers and has been one of our high-use areas. We have seen an increase in patient access now that the bill is in effect.
Have any organizations currently using insurance billing experienced a delay in starting treatment while waiting for cooling cap benefits to be confirmed, and prior authorization (PA) to be approved or appealed?
Yes. When this happens, we suggest facilities consider doing benefit investigations in-house.
Will hospital facilities need to provide patients with the cap directly?
Yes. Facilities will have cap kits in their inventory and will provide them to patients.
Will there be additional Relative Value Units (RVUs) associated with these codes?
We are not aware of any Relative Value Units (RVUs) being assigned to the three codes at this time.
What are the steps we need to take in order to switch to insurance billing?
Familiarize yourself with all the information available on our dedicated webpage, and then contact reimbursement@paxmangroup.com to request a meeting.
You will then need to:
1. Amend your contract or execute a new contract with Paxman.
2. Set up an account to order cap kits.
3. Program your EMR with the new codes.
4. Determine pricing for insurance billing and direct pay.
5. Conduct implementation and training.
When it comes to billing for post-chemotherapy (97009), does the documentation need to denote fully completed 30-minute increments?
Yes. Cooling increments should be a full 30 minutes.
Are there upfront costs and fees associated with switching if we already have Paxman machines?
The only cost associated with switching is purchasing cap kits so that you have them in inventory to provide to patients. Your facility will need to execute an amendment or new contract before making the switch.
At any given center, what is the average proportion of patients that receive reimbursement versus those that are denied?
We dont receive that data from our customers.
What would you advise for a center that has been unable to get reimbursement?
With Category I CPT codes now available, we expect more centers to receive reimbursement.
For the new Category I CPT codes, what is meant by the self-administered guidelines?
The Category I CPT codes are intended for use with mechanized scalp cooling, which requires clinical assistance. Currently, only Paxman and DigniCap require this. Self-administered scalp cooling is performed without clinician oversight or assistance; therefore, billing for it using CPT codes is inappropriate because it is not a clinician-assisted process.
Is there a good summary of scalp cooling efficacy for each type of chemotherapy?
Yes. We have an outcomes calculator, clinical guidelines, and a comprehensive clinical studies library.
Our available resources on the Scalp Cooling Registrya real-world study of over 7,000 patientsalso provide 13 years worth of efficacy data across 24 chemotherapy regimens in several accessible formats.
Is there still going to be a self-pay model?
Yes, but our hope is that all facilities move to insurance billing to provide greater access for patients.
Does Paxman provide support to set up the infrastructure to use insurance billing?
Yes. We provide information, guidance, and best practices from other customers and key opinion leaders using insurance billing.
Does the cap fitting and initial education need to be completed by an RN in order to charge 97007?
No. It can be billed by anyone who has been trained by Paxman to do so.
Does Paxman investigate insurance coverage and costs for the patient, or will the practice be responsible for this?
The Paxman Hub, administered by CoverMyMeds, can conduct a benefits investigation, or your facility may do so. Some facilities prefer to do it in-house.
Will patients have to order anything directly from Paxman anymore? Will this be done by the facility with the nurse providing the patient with what they need?
The facility will have cap kits in inventory and will provide them to each patient.
Is the patient expected to pay and then submit for reimbursement from insurance?
No. The facility will submit a claim to the patients insurance along with all of the other charges for the patients treatment.
How does the donation process work?
Patients can contact patient@paxmangroup.com for more details. In the regrettable instance where a patient requires additional chemotherapy, they may wish to consider keeping the cap.
Which insurance companies cover scalp cooling?
Coverage is policy-specific rather than insurer-specific. Certain plans offered by insurance companies will offer coverage, while other plans offered by the same insurance company may not. Its common for insurance policies to have carve-in or carve-out policies.
Read Memorial Sloan Kettering’s paper on the implementation of a scalp cooling program
Request a Paxman Dossier
A Paxman Scalp Cooling Dossier is available to provide relevant clinical and health economic information. You can request a copy below:
