AMA: Commercial Coverage of Digital Medicine Services is Inconsistent

Commercial coverage policies for digital medicine Current Procedural Terminology (CPT) codes are inconsistent and lag behind Medicare, an issue brief from the American Medical Association (AMA) found.

Commercial payers often cover similar services as Medicare, but coverage and payment policies may differ between private and public plans. As digital care utilization increases, AMA and Manatt Health assessed publicly available coverage policies for commercial plans to determine how these payers cover 21 digital medicine services.

The brief analyzed coverage policies of 16 commercial health plans: Aetna, Blue Cross Blue Shield of Illinois, Massachusetts, Michigan, North Carolina, Texas, Blue Shield of California, CareFirst Blue Cross Blue Shield, Cigna, Elevance Health, Florida Blue, Highmark Blue Shield, Horizon Blue Cross Blue Shield of New Jersey, Regence, Tufts Health Plan, and UnitedHealth Group.

AMA identified a lack of coverage alignment across commercial payers, Medicare, and Medicaid. Medicare and Medicare Advantage plans covered all 21 digital care services. However, private health plans in Medicare Advantage did not offer the same coverage in the commercial market.

In addition, some commercial plans had restrictions beyond what CPT and Medicare require, such as only covering codes for specific indications or not reimbursing for a particular category.

Across the commercial market, there were inconsistent coverage policies for digital medicine CPT codes. Some plans had concrete clinical coverage policies, while others did not have explicit coverage but may still pay claims for the codes if providers bill them. Payers without clear coverage policies typically default to state rules, the brief noted.

Most commercial payers covered remote patient monitoring, but several were still considering coverage of newer remote therapeutic monitoring codes. Meanwhile, coverage of electronic consults and visits was less consistent.

The transparency of plans’ coverage policies for digital medicine services also varied, with some payers having publicly available clinical coverage policies and others having dated or no information.

“While the United States has entered an era when digitally enabled care is integrated with in-person care, the potential of this hybridized care model is not yet fully realized,” Jesse M. Ehrenfeld, MD, president of AMA, said in a press release.

“The lack of commercial coverage can be a roadblock or bottleneck to affordable access to digital medicine services for more than half the US population who count on private health insurance. Barriers to clear and consistent coverage policies must be addressed for the pace of digital health progress in medicine to match the technology’s promising potential.”

Commercial payers shared that there is no specific timeline for reviewing and making coverage decisions about the digital medicine services included in the analysis. After a new CPT code is created, it may be several years before commercial plans cover the codes, making it hard for providers to invest in digital programs.

On the other hand, payers reported that a limited number of healthcare providers are using digital medicine services. This can make it difficult for payers to understand the impact and quality of these services, two factors that can inform coverage decisions.

Some commercial payers have partnered directly with health technology companies to offer members direct access to digital care services for specific disease areas, such as hypertension, behavioral health, and physical therapy. Although these collaborations can improve access to digital care, they are often disconnected from a patient’s primary care physician, leading to fragmented care.