Optellum joined the small group of imaging AI vendors who are on a path towards reimbursements, representing a major milestone for Optellum and another sign of progress for the business of imaging AI.
With Optellum’s “New Technology Ambulatory Payment Classification” (NTAPC), providers who use the Optellum Lung Cancer Prediction solution with Medicare patients can bill CMS $600-$700 for each use (CPT: 0721T).
Physicians would use Optellum LCP to analyze a Medicare patient’s CT scan, leveraging Optellum’s pulmonary nodule risk scores to support their decision whether to refer the patient to a pulmonologist. Then they would bill CMS for reimbursement.
However, like previous NTAPCs, this is just the first step in Optellum’s path towards full reimbursement coverage:
- Regional Medicare Administrative Contractors will initially decide whether to reimburse on a case-by-case basis (and can decline reimbursements)
- A similar process will happen with private plans
- Reimbursements would only be nationally required once Optellum LCP is covered by each of the 12 MAC geographies and all commercial payors
Although not guaranteed, Optellum’s CMS-defined reimbursement rates/process represents a solid first step, especially considering that Perspectum and HeartFlow’s previous NTAPCs led to widespread coverage.
Optellum’s NTAPC also continues imaging AI’s overall progress towards reimbursements. Within the last two years, Viz.ai and Caption Health scored the first AI NTAPs (guaranteed add-on payments, but temporary) and startups like Nanox AI, Koios, and Perspectum landed AI’s first CPT III codes (reimbursements not guaranteed, but data collected for future reimbursement decisions).
The Takeaway
Although reimbursements are still elusive for most AI vendors and not even guaranteed for most AI products that already have billing codes, it’s clear that we’re seeing more progress towards AI reimbursements. That’s good news for AI vendors, since it’s pretty much proven that reimbursements drive AI adoption and are necessary to show ROI for many AI products.
