WALT-NAALT Joint Conference 2014 Arlington, VA USA
Insurance Reimbursement for Photobiomodulation
Co-Chairs: Doug Johnson and Donald Patthoff
Attendees: Jan Bjordal, David Rindge, Timothy Demchak, Chris Carraway
Insurance reimbursement has been identified as playing a significant role in moving the science of photobiomodulation (PBM) forward. The aim of this position paper is to outline key considerations and obstacles in gaining insurance recognition and reimbursement. Presently, some of the basic biological mechanisms of PBM are known. This understanding, though, is evolving and clearer maps of the pathways of actions are necessary for mainstreaming acceptance. PBM, however, is already used in a variety of disciplines including physical medicine and rehabilitation, chiropractic, dentistry, neurology and ophthalmology and will continue to play a significant role in the future of our ever changing and evolving health care system.
Photobiomodulation, low level light therapy, or other terms associated with this field are not adequately identified as insurance reimbursable items-of-care, nor are there adequate actuarial analyses of the key risks and benefits that help structure realistic reimbursement schedules. Consequently, the insurance industry has not yet adopted photobiomodulation (low level laser and light therapy) as part of their mainstream products. The Centers Medicare Services, major insurers (Blue Cross/Blue Shield, AETNA, Cigna and Workers’ Compensation plans) and third party payer systems classify the use of light “experimental and investigational” in their policy and update bulletins.
With over 30 ( perhaps 72) key words now being used in the literature regarding this field, a consensus in establishing common search terms to help better collate this information will improve the ability of these company reviewers’ to find good, quality articles for inclusion and discussion in these types of reviews. Several authors have critiqued these “inconclusive” reviews however; have not impacted the review process used to create these types of insurance policies. So, while many of these insurance stances/policies can be faulted because of poor methodology and inclusion biases, without proper discussion or collaborative efforts between the PBM community and the insurance carriers, this will simply be two one-sided discussions.
In short, insurance reimbursements for PBM related procedures are non-existent partly because there are no clear codes for procedures based on this service. Independent actuarial analyses of the risks and benefits of PBM therapy versus other modalities and procedures can be used to support the use of PBM in mainstream practice. Reports from centers of excellence can also help support the appropriate use and reimbursement of PBM. A change in the reimbursement status could persuade healthcare professionals to adopt PBM into clinical practice with the potential ability to get a potential return on their investment.
Healthcare professionals are reluctant to purchase medical devices that have little reimbursement; without a reasonable direct return on investment, indirect benefits must be demonstrated as hypothetical until comprehensive outcome data is collected and compared. Clinical use of PBM is still growing, however it can be limited to a “marketing” tool because it works, and practitioners and their patients get what they expect. Others operate strictly on cash-pay. Some clinicians opt-out of participating in any insurance agreement if it limits or restricts their preferred practice patterns and patient wants.
The Current Procedural Terminology (CPT®), is a coding system owned by the American Medical Association. The Current Procedural Terminology (CPT®), Fourth Edition, has the most recent. The purpose of CPT is to provide a uniform language that accurately describes medical services and procedures medical, surgical, and diagnostic services for reliable communication among physicians and other healthcare providers, patients, and third parties.
All Insurance companies and the Medicare/ Medicaid systems utilize the CPT code set for determining medical benefits and reimbursement for medical services and procedures. The lack of specific CPT® codes to identify and describe the application of laser/ light for treatment or diagnoses known to positively respond to PBM maybe the largest obstacle to overcome. Currently providers often submit “other” related codes (with mixed results) for reimbursement (97026, 97140, 97039 within physical therapy, for example). Medical organizations such as NAALT, WALT, ASLMS, and ALD etc. may submit applications for changes to CPT for consideration by the Editorial Panel. Simply completing the information requested, however, does not ensure that the CPT Editorial Panel will adopt a suggestion; the CPT Editorial Panel meets three times each year. CPT's must reflect current practice.
A new descriptor/code requires:
- a complete description of the procedure/service (e.g. describe in detail the skill and time involved)
- a clinical vignette which describes the typical patient and work provided by the physician/practitioner
- the diagnosis of patients for whom this procedure/service would be performed
- a copy(s) of peer reviewed articles published in US journals indicating the safety and effectiveness of the procedure, as well as the frequency with which the procedure is performed and/or estimation of its projected performance
- a copy(s) of additional published literature which you feel further explains your request (e.g., practice parameters/guidelines or policy statements on a particular procedure/service)
- evidence of FDA approval of the device used in the procedure/service
A CPT is only effective, though, if an insurance company will actually pay. That conversation - for what a company will pay – depends, however, on the various contracts that employers and 3rd party purchasers work-out with each insurance company about each specific policy’s limitations concerning, for example, what will or will not be reimbursable coverage. And, not all procedural items are reimbursed. To establish reimbursement for use of a specific product in health care, a product must be new, must substantially improve upon existing treatments, and must be of “sufficient” cost. This, in turn, requires adequate published U.S. peer-reviewed clinical recommendations and economic data. While good data does exist that validates the use of PBM, there is clearly a lack of documented widespread use, clinical comparative evidence, and coherent support from any single professional society(s) representing a key discipline such as physical therapy, ophthalmology, or dentistry.
In this regard, however, most insurance companies will often follow recommendations set by Centers for Medicare & Medicaid Services (CMMS). To that end, because Medicare and Medicaid have strong political ties, effective lobbying by a Political Action Committee (PAC) representing the expertise and interests of the PBM community would be needed. Such a PAC would need to compete or collaborate with other PACS as is aims to influence key senators and congresspersons to help recognize the value and importance of PBM.
Information has been compiled to identify obstacles that limit broader acceptance of PBM based modalities. These other obstacles need to be pointed out if the insurance coverage and reimbursement barriers are to be lifted. The broad make-up of the entire PBM community itself which has greatly helped advance this field, for example, also becomes a hurdle. Photobiomodulation is utilized in a variety of medical, dental and allied health professionals – each with their own professional ethics, standards and organizational goals that are, in turn, each linked by their particular uses of light and lasers as therapeutic interventions.
This diversity, with both its strengths and weaknesses, spans across many disciplines. It shapes a shared common-experience that comes from many different perspectives; it combines the expertise of each respective field as well as numerous safe and effective use experiences. The weakness of this expanse diversity is that the general membership of each specific discipline finds it hard to focus on their narrow PBM techniques when such widespread uses - in a multitude of conditions and circumstances - are expanded to this broad variety of other practice settings. Questions quickly arise: Are all members of their specific association qualified (licensed or registered) to provide this treatment? Does it fall within their scope of practice? In short, the very wide spread and scattered use of light therapy leads to either a mentality of “too good to be true” or pre-mature questions/statements about availability of “practice” standards and training.
NAALT could help host a “summit” aimed to organize public policies and position papers. These would need to focus on direct legislative efforts. To start, interested manufactures and key clinical groups would need to form a working group that, in turn, would petition larger medical organizations such as the AMA and ADA to help assist other manufacturing groups create economic value propositions that will effectively advocate for specific kinds of reimbursement. Another key approach to developing the support needed for insurance codes and reimbursements to be better justified would be the development of a center of excellence or a network of centers that are developed within existing clinical and translational research initiatives.
In summary, to establish insurance reimbursement for photobiomodulation procedures, it will need clear definitions for purposes of coverage policy, a list of procedural codes, an established fee schedule, and assurances of how it can be monitored. At present, PBM lacks all four components. NAALT may need to work with other organizations such as WALT, ASLMS, ALDS and, perhaps OSA, etc. to collect this data. These, then, will also need to approach other professional, clinical organizations such as the AMA, ACA, ADA, APTA and NATA as well as any industry coalitions that develop over the next several years.
A plan of action should include:
- Support of US Based Clinical Trials that focus on translational research
- Establishment of PBM cost analyses and comparable procedures
- Adoption of common nomenclatures to standardize the literature
- Involvement in the review process with insurance carriers for policy determinations
- Documented use of PBM in specialty practices
- Lobbying professional organizations for common goals/interests for mutual benefit
- Submitting Applications for CPT Codes
- Approaching specific industries in regards to common interest/goals
- Concentrate initial “forward progress” on a focused group of specific conditions/procedures
- Register as a PAC with the Federal Election Committee (FEC)