Richard Paxman: The road to scalp cooling reimbursement in the U.S.

Richard Paxman, Chief Medical Officer and Managing Director at Paxman, shared a post on LinkedIn:

“As we wrap up after a fantastic San Antonio Breast Cancer Symposium (SABCS) and look towards 2025, I want to reflect on one of this year’s biggest milestones in enabling scalp cooling access in the United States: the issuance of Current Procedural Terminology (CPT®) Category I codes for mechanical scalp cooling from the American Medical Association(AMA).

This major breakthrough for Paxman and mechanised scalp cooling came following our presentation made at the September 2024 AMA conference in Albuquerque. After several years of using temporary CPT® Category III codes, the subsequent announcement by the AMA on October 18th confirmed a permanent code structure, offering a vital step in our efforts towards widespread access.

This achievement sets Paxman up perfectly to align with our own vision:

Regardless of gender, ethnicity, cancer type, chemotherapy type or location and financial situation, every patient should have access to our technology.

The CPT® I coding will become effective from January 1, 2026, with descriptors included in the CPT® 2026 code set, enabling us to begin unlocking further IBBM coverage and payment with far greater confidence.

Accessing Reimbursement

In the United States, accessing scalp cooling, from a financial perspective, is best achieved through our Insurance-Based Billing Model (IBBM). Developed using the current CPT® Category III codes which will eventually be brought in line with the new announcement, it provides healthcare practices with a streamlined way to offer scalp cooling while billing insurers directly. For healthcare providers, it involves establishing a contract with Paxman and one of our distribution partners, in addition to comprehensive training for billing.

For underinsured or uninsured patients who are unable to access scalp cooling treatment via insurance, our Patient Assistance Program (PAP) is designed to provide crucial support.

Qualifying patients receive a cap kit and scalp cooling treatments free of charge. The cap comes from the provider, which is then subsequently replaced by the Paxman Hub.

As the CPT® I coding comes into effect from January 1, 2026, we will also be continuing our work with longstanding Paxman users across US healthcare systems that have implemented Paxman scalp cooling under the self-pay business model to transition across to the IBBM. This will enable them to remove the barrier of financial toxicity and widen patient access to this important means of side effect management for their patient community.

Navigating the transitional phase

Coding, Coverage and Payment conversations are a hot topic of conversation at events like SABCS with our current clinical partners and HCPs, having precipitated renewed credibility and confidence in scalp cooling as a permanent addition to cancer treatment in the United States.

We have already worked through the transition from self-pay to IBBM with many cancer centres while CPT® III coding has been in place providing up to 75% coverage rates and reasonable payment to HCPs. During 2023, the Palmetto GBA Medicare Administrative Contractor (MAC) also issued a Local Coverage Determination (LCD) further supporting the coverage for scalp cooling. Preparation for existing Paxman Scalp Cooling facilities is a key objective over the course of 2025, ensuring healthcare systems are poised for the transition from the current CPT® III coding or directly from the self-pay model to our Insurance-Based Billing Model (IBBM). Under the current CPT® III coding, we have recognised the complexities in deploying previous transitions of facilities offering scalp cooling via the self-pay model to the current IBBM. As such, we are committed to spreading the word and providing a clear transitional framework for our existing facilities, ready for 2026.

Another key focus, which continues into 2025 and beyond, is raising awareness of this new permanent coding, deploying valuable educational and preparational resources, with support from our teams. We are confident that the announcement will act as a catalyst for securing increased coverage both via CMS (LCDs) and commercial payers as well as having a positive effect on the Hospital Outpatient Prospective Payment System (OPPS) and the Medicare Physician Fee Schedule (PFS). The OPPS governs hospital outpatient facility payments while the PFS governs physician/provider payments regardless of location. When services such as scalp cooling are provided in hospital outpatient settings, hospitals are paid under OPPS, and physicians are reimbursed under PFS for their professional services.

The value of mechanised scalp cooling as a means of side effect management is already acknowledged by guideline organisations such as NCCN®, and its integration into legislation highlights the importance of the treatment.

We share the belief it shouldn’t be limited by financial means, underscoring the need for physicians and organisations within the US healthcare system to address the potential devastating side effects of chemotherapy on a patient’s quality of life.

Ending the year on a positive note, the New York State Governor Kathy Hochul signed a bill this month to provide insurance coverage for scalp cooling systems used to preserve hair during chemotherapy treatment for cancer. Taking effect from January 1, 2026, the bill legally requires private health insurers to provide coverage. It is the first state in the U.S, to do so, setting a great example for other states and draws us even closer to our goal of universal access to scalp cooling.

An exciting year ahead

The upcoming holiday season gives us brief pause to relax and reflect on a successful 2024 in widening patient access to scalp cooling. As we step into 2025, the focus shifts to implementing this hard-won achievement.

Alongside the years of hard work from the Paxman team, I am also grateful for our partnership with Dr. Steven Isakoff of Massachusetts General Hospital. I would like to thank the following societies for their active engagement and support: American Society of Clinical Oncology (ASCO) American College of Obstetricians and Gynecologists (ACOG) and AAP (American Academy of Pediatrics).

Visit our page on reimbursement for more information on expanding access to the life-changing treatment of scalp cooling for your patients.”

Richard Paxman is the Chief Medical Officer and Managing Director at Paxman. Previously, he was an Operations Director at Paxman Coolers Limited. He has also served as the General Manager at Brewfitt Limited.