Joseph Perekupka
Digital therapeutics have significantly improved access to care for many patients, while delivering consistent clinical outcomes across a wide range of conditions. However, despite the potential these new treatments offer, convincing payers to embrace the risks associated with new treatments has been an incredible challenge. The newly-proposed fee schedules from the Centers for Medicare & Medicaid Services (CMS) could be pivotal in mitigating that risk for payers while also encouraging providers to embrace the use of digital mental health treatments for their patients.  .
CMS’s recently released 2025 Medicare Physician Fee Schedule proposes new reimbursement codes for digital tools that support the delivery of FDA-cleared behavioral health treatments when included as part of a broader treatment program. While currently limited to digital mental health therapeutics (DMHT), this proposal is a considerable milestone. If enacted, it will represent the first major step toward broad-based reimbursement for digital therapeutics, and acknowledgement that CMS recognizes the substantial role new digital solutions can provide.
Currently, there is no widespread reimbursement for digital therapeutics despite their ability to improve access to care and patient treatment adherence. But progress is being made, in 2022, CMS established HCPCS code A9291 for digital behavioral health therapies, although a fee schedule has yet to be set for that code. Despite that insurance companies have been slow to add digital mental health treatments as a benefit for their members but the new codes proposed in July provide a reason to be optimistic. Â
The new proposed codes are not going to solve all the reimbursement challenges the sector faces and may require fine-tuning to ensure reimbursements are optimized for the different treatment models. But, if the proposed fee schedule is passed it promises a number of benefits that could ultimately pay dividends for digital health manufacturers and behavioral health providers. The credibility of such a decision by CMS will validate the need for digital therapies and thus boost investor confidence in the sector as a whole, establishing a potential revenue pathway, especially for digital mental health companies. The broader goal of this move is to drive adoption of these solutions, which will lead to better datasets validating the need, willingness and effectiveness of digital health solutions. Most importantly, the existence of these codes is likely to spur further innovation, accelerating the evolution of digital solutions as more companies enter the market with the assurance of a viable path to reimbursement and a sustainable revenue model.
The introduction of Medicare reimbursement codes for digital mental health solutions could lead to the rapid adoption of new technologies from telemedicine to at-home treatments. This development has the potential to help overcome significant barriers to care that many face, especially in underserved communities. Most importantly, it will provide patients the opportunity to find the best clinical pathway tailored to their care needs which will empower patient populations to take an active role in their own health.
Photo: Elena Lukyanova, Getty Images
Joseph Perekupka is the CEO of Freespira, the only company to offer a medication-free, FDA-cleared digital therapeutic treatment proven to reduce or eliminate symptoms of panic disorder, panic attacks and PTSD in 28 days. Joe is a proven healthcare leader with over 25 years of commercial experience in multiple leadership and functional medical device and digital health roles. He plays an active role with organizations such as the Digital Therapeutics Alliance and DTx societies, where he maintains co-chair roles that are focused on propelling the DTx industry growth, and is passionate about creating equitable access to care for mental health patients nationwide.
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