Starting January 1, 2026, New York will become the first state in the nation to require insurance coverage for scalp cooling therapy—a significant policy shift that blends clinical care with psychosocial support and recognizes the profound psychological impact of chemotherapy-induced hair loss. Especially pertinent to patients with breast cancer, this new law mandates that large group health plans cover FDA-approved scalp cooling systems and related services, transforming what was once dismissed as “cosmetic” into a covered medical necessity.
For healthcare providers, this landmark legislation presents both an opportunity and an operational challenge: ensuring patients can access this life-changing therapy while navigating new billing requirements, payer protocols, and workflow adjustments. In this Q&A, Aspirion’s Rikki Ashkin, J.D., Director Legal COE, and Elizabeth Purdy, J.D., Associate Attorney, break down what providers need to know to prepare their hospitals for successful implementation.
Q: What is New York’s new scalp cooling insurance law?
Elizabeth Purdy: Effective January 1, 2026, New York’s Scalp Cooling Coverage Law (A.38-A / S.2603-A and A.430) requires large group health insurance policies to cover FDA-approved scalp cooling systems and related services for patients undergoing chemotherapy. This mandate amends Insurance Law §§ 3216, 3221, and 4303. New York is the first state in the country to enact such a requirement. Scalp cooling reduces chemotherapy-induced hair loss by constricting blood vessels in the scalp and limiting the amount of chemotherapy drugs reaching hair follicles. Devices like Paxman and DigniCap have shown up to 65% effectiveness in preventing hair loss for specific chemo regimens.
Q: Who is impacted by the law?
Rikki Ashkin: The law applies to large group health insurance policies issued, renewed, modified, or amended in New York on or after January 1, 2026. It does not apply to small group or individual market plans. Providers, including hospitals, infusion centers, and oncology practices, must prepare to offer scalp cooling therapy as a standard, covered service. Insurers, on the other hand, must provide coverage for FDA-approved scalp cooling devices used alongside chemotherapy as well as the Professional and technical services necessary to administer the therapy.
Q: How should providers prepare operationally?
Elizabeth Purdy: Hospitals and oncology centers should take several proactive steps such as reviewing payer contracts for outdated language categorizing scalp cooling as “cosmetic” or “elective.” Such classifications must be updated to reflect its status as medically necessary. Additionally, providers should train staff on new workflows, patient consent, counseling, and integration into chemo treatment planning. We also recommend updating clinical protocols to reflect scalp cooling as a covered therapy for regimens likely to cause alopecia.
Q: Will prior authorization be required?
Rikki Ashkin: Possibly. While the law mandates coverage, payers may still implement prior authorization requirements. Providers must confirm payer-specific prior authorization rules before administering therapy. Failure to secure required authorization, even when the service is medically necessary, may result in retroactive technical denials. To mitigate risk, we recommend that providers confirm authorization policies before Jan. 1, 2026, train staff to recognize when prior authorization may be needed and also building automated prompts into EHR workflows for authorization flagging.
Q: How should providers prepare billing and coding teams?
Elizabeth Purdy: Expect new or updated CPT and HCPCS codes for scalp cooling services. Coding teams should align with infusion centers and oncology departments, stay current on device-specific identifiers and coding guidance, and avoid billing discrepancies that could lead to denials during early rollout.
Q: What should providers expect regarding claim denials?
Rikki Ashkin: Payers may initially deny claims during the transition period. Providers should be prepared to appeal any denial for scalp cooling that cites lack of medical necessity or coverage. Appeals should reference the amended Insurance Law §§ 3216, 3221, or 4303(12-b). If insurers delay compliance, providers may also cite New York’s Unfair Claims Settlement Practices Act (§ 2601). To ensure a timely response, appeal templates should be developed in advance and ready for use when denials begin in early 2026.
Q: How might this law affect patient volumes or workflows?
Elizabeth Purdy: Scalp cooling therapy requires scheduling time, trained staff, and specialized equipment. Providers should forecast increased demand for scalp cooling and ensure sufficient inventory and technician availability. We also recommend adjustments to infusion scheduling to accommodate additional therapy time.
Q: What immediate steps should providers take before January 1, 2026?
Rikki Ashkin: At a minimum, Providers should begin by identifying covered populations through a review of payers governed by New York law. They should also map historical scalp cooling denials to inform future appeals. Workflow flags should be implemented in EHRs for chemotherapy regimens likely to cause hair loss. Eligible patients should be tracked using a scalp cooling registry, with clinical rationale documented. Billing, coding, and clinical teams should be trained on updated protocols. Finally, patient materials should be revised to include information on scalp cooling options and insurance coverage.
Q: Will further guidance be issued?
Elizabeth Purdy: Yes. The New York Department of Financial Services (DFS) is expected to release implementation guidance ahead of the law’s effective date, including documentation and cost-sharing standards.
Healthcare providers should act now to update systems, train staff, and prepare patients to ensure smooth implementation by January 1, 2026. For hospitals seeking to navigate this new policy shift, contact Aspirion today to learn how we can help.
