Pathways’ Pick of the Week: Pear Gets CMS Code

Pear Therapeutics’ suite of prescription digital behavioral therapies and future FDA-cleared software-based tools can be billed as a durable medical equipment benefit to private insurers and other non-Medicare payors starting April 1, now that CMS has granted a new Healthcare Common Procedure Coding System (HCPCS) Level II code. The code (A9291, “Prescription digital behavioral therapy, FDA cleared, per course of treatment”) was sought by Pear to support its reSET (substance use disorder), reSET-O (opioid use disorder), and Somrys t (chronic insomnia) systems. In the near term, it offers an additional reimbursement pathway beyond the pharmacy benefit that Pear’s prescription software has also leveraged. But digital health developers also hope the decision is a positive signal from CMS that prescription digital therapeutics (PDTs) warrant coverage and payment. Currently, there is no Medicare benefit category for PDTs, so they aren’t covered by the federal system. Industry groups have been talking to CMS about ways to incorporate digital tools into the existing statute and, in addition, the Digital Therapeutic Alliance (DTA) is lobbying Congress for legislation to establish a benefit category. “Establishing a HCPCS code for prescription digital behavioral therapies is an important first step to ensure patient access to [digital therapeutics] products,” said Andy Molnar, DTA’s CEO.

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