Commercial payers beginning to define coverage of RPM and RTM

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During the COVID-19 public health emergency (PHE), the majority of commercial health insurance payers decided to cover remote patient monitoring (RPM) on an interim basis. Now, with the expiration of waivers associated with the PHE, commercial payers have begun to determine their position for ongoing coverage of RPM and remote therapeutic monitoring (RTM) services. While Medicare has expansive coverage of both RPM and RTM, private payers, as well as state Medicaid programs, vary greatly on whether and the degree to which they will be reimbursing these services.

A September 2023 American Medical Association (AMA) report, "Future of Health: Commercial Payer Coverage for Digital Medicine Codes," provided an analysis of commercial payer coverage of digital medicine CPT codes, which includes those associated with RPM (CPT 99453, 99454, 99457, 99458, 99473, and 99474) and RTM (CPT 98975, 98976, 98977, 98978, 98980, and 98981). The report drew several conclusions, notably that there is:

• lack of coverage alignment across commercial, Medicare, and Medicaid;
• inconsistent adoption of digital medicine CPT codes within the commercial market; and
• inconsistent levels of transparency related to coverage of digital medicine codes.

Although the AMA report is the most comprehensive report to date, it only includes information on 16 of the dozens of large private health plans throughout the country. Of those 16, AMA was only able to receive clear validation from 10 of the companies they surveyed. With consumer and provider demand for remote monitoring increasing, insurance companies will continue to be pushed to publish clear coverage policies on the subject.

Given the currently released policies and where we see the market going, we see three major stances insurance companies can and will take.

Mirror medicare coverage

Some private payers will mirror Medicare's coverage of RPM and RTM. Medicare has been the driving force behind the RPM codes and gives providers great flexibility in choosing which conditions and patient cohorts utilize RPM. A provider identifies the condition(s) they would like to manage remotely and launches an RPM program to offer the service to patients. Medicare RTM coverage is similar but is restricted to specific condition types or modalities (e.g., respiratory system status, therapy response).

After enrollment in either program, the patient is then provided with a device to collect the physiological or therapeutic data. RPM and RTM devices must be electronically connected. Once the device is set up appropriately, health data is captured by the device and transmitted from patient to provider, usually electronically. The provider analyzes this data and gives the patient health and wellness guidance based upon the results.

AMA has determined that Blue Shield of California is one such health plan currently mirroring Medicare's approach to RPM and RTM coverage. The AMA report also shows that some payers such as Elevance (previously known as Anthem) mirror Medicare coverage for just RPM while not yet paying for RTM at all.

Cover specific conditions/modalities

Some commercial payers will choose the conditions/modalities and CPT codes they cover. One commercial payer that has defined how it is covering RPM and RTM, and which demonstrates how complicated private payer rules can be around coverage, is Cigna. In its medical coverage policy with an effective date of Nov. 11, 2023, Cigna notes it is considering RPM medically necessary for any of and only the following conditions:

• Chronic obstructive pulmonary disease (COPD)
• Diabetes mellitus
• Heart failure

The payer then identifies a series of requirements for the technology that must be used to capture and transmit the physiologic data.

This is a very restrictive policy compared to Medicare in that it rules out the use of RPM in many patient conditions where it has shown efficacy, such as hypertension and preeclampsia monitoring. Cigna's policy also prevents physicians from using their judgment to innovate RPM programs past the traditional RPM conditions.

Cigna notes it considers RTM not medically necessary for all indications — in other words, it is not providing coverage of RTM. To justify its decision, Cigna states, "There are limited published, peer-reviewed data regarding the effect of RTM on health outcomes. At this time there is insufficient evidence to support improved health outcomes with remote therapeutic monitoring compared to standard of care clinical practice." Yet, the AMA report notes that commercial health plans such as Aetna, several state Blue Cross Blue Shields, and Tufts Health Plan are covering RTM (as well as RPM).

Disallow coverage

Some private payers are thus far choosing not to cover RPM or RTM. As of August 2023, the AMA report notes that Florida Blue is not covering RPM. Concerning Florida Blue's coverage of RTM, AMA indicates there is no public information on coverage status or no coverage decision has yet been made.

We expect the number of commercial health plans not covering RPM and RTM to steadily decline due to external pressures. Contributing pressures will include evidence of efficacy and cost savings, growing patient and provider demands, and state laws.

The trend towards coverage

It will be interesting to see how commercial payer coverage of RPM and RTM changes in the coming months. This was a topic I spoke about during a recent webinar on the 2024 PFS final rule. Over this past year, new and expanded studies have been published that demonstrate the clinical benefits of RPM in different settings, particularly for hypertension, heart failure, COPD, and diabetes. As the usage of RPM and RTM continues to increase, we can expect more studies to be published on the effectiveness of RPM and RTM. Further, these studies will start to make clear which configurations or types of RPM and RTM programs are the most efficacious and cost efficient, which should lead to expanded commercial coverage of the services.

While some private health plans have hesitated to cover RPM and RTM, CMS has indicated it is already confident about the high value of the services when they are furnished appropriately. Evidence of this came in the 2024 Medicare Physician Fee Schedule (PFS) final rule. The rule finalized that starting in 2024, Medicare will cover RPM and RTM when furnished by federally qualified health centers (FQHCs) and rural health clinics (RHCs). For FQHCs, RPM and RTM are now included in general care management HCPCS G0511. This further points to CMS recognizing the value of expanding access to these and other remote care management services.

Given the growing body of evidence supporting the usage of RPM and RTM and the federal government's embracing of the services, we will hopefully see insurance companies standardize their coverage. This will help avoid member confusion and provide greater access to services that are helping improve outcomes, reduce costs, overcome social determinants of health barriers, and deliver many other benefits.

Daniel Tashnek is the co-founder of Prevounce Health, a healthcare software company that simplifies the provision of preventive medical services, chronic care management and remote patient management. Daniel is also a practicing healthcare attorney specializing in regulatory compliance, reimbursement, scope of practice, and patient care issues.