Payor Policy & Coverage Comment Letters
The AGA Institute is committed to ensuring that physicians and their patients have access to clinically effective diagnostic and therapeutic tests and procedures. Our Payor Policy Work Group (PPWG) periodically receives requests from payors and Medicare contractors to review and provide comments and feedback regarding language and coverage determinations in their draft medical policies. In addition, we conduct ongoing review of coverage determinations that impact gastroenterology.
As part of our commitment to transparency, letters from the AGA Institute regarding coverage issues will be available on this page.
What the PPWG can do:
- Review payor/contractor medical coverage policies related to gastroenterology that are considered not medically necessary, unproven, investigational or experimental and comment if appropriate.
Review denied claims based on the following and comment if appropriate:
- incorrect CPT/HCPCS coding guidance by payor.
- payor acceptance of modifiers and/or interpretation of NCCI/MUE edits.
- payor policies requiring services to be performed in a specific setting solely for financial reasons, where there may be a concern about patient safety.
- issues at odds with AGA or other specialty society guidelines.
- issues for denied/non-covered procedures/tests/drugs with peer reviewed, published literature that describes the procedure including site of service, identifies the target population for the procedure including diagnostic evaluation and/or therapeutic management, and/or demonstrates sustainable health outcomes for patients.
What the PPWG cannot do:
- Write appeal letters for specific denied claims.
- Write appeal letters on behalf of a specific patient.
- Review Medicare Recovery Audit Contractor (RAC), Zone Program Integrity Contractor (ZPIC) or other payor/billing audits.
- Review requests from law firms on behalf of a specific provider
- Give financial or legal advice.
Are you experiencing an issue with coverage for a GI service or test? Let us know by completing this form and submitting to the PPWG.
*The AGA reserves the right as to whether or not to comment on the issue. A decision by the AGA as to whether or not to comment on an issue does not imply AGA endorsement or lack thereof for the procedure / technology / diagnostic / pharmaceutical in question.
One letter on each issue is linked below. For copies of letters to additional payors listed, please contact Jennifer Conte.