Remote Physiologic Monitoring (RPM) (CPB 1093, reviewed 2026-05-31)

IMMEDIATE (before 2026-05-31): 1) Billing team must update billing system validation rules to require documentation of: (a) FDA device approval/clearance status, (b) automatic data transmission capability, (c) patient consent authorization, (d) qualified provider ordering/supervision, and (e) clinical impact on treatment plan adjustment. 2) Implement hard stop in billing software to prevent claim submission for RPM codes (99453, 99454, 99457, 99458, 99445, 99470) unless all five criteria above are present in the patient record. 3) Update preauthorization templates to require these five elements before approval. 4) Configure system to enforce one-episode-per-month limit per patient per condition per provider—flag and deny claims exceeding this threshold. 5) Train providers and billing staff that RPM is only covered for three conditions (heart failure, hypertension, diabetes); claims for other conditions will be denied as experimental/investigational. 6) Providers must document that data collected is being used to modify the member's treatment plan; RPM solely for tracking or wellness will be denied. 7) Reject any claims using non-FDA-approved devices or apps (e.g., general wellness trackers). 8) Verify ICD-10 diagnosis codes on all RPM claims match covered conditions (E08-E13 for diabetes, I10/I1A.0/I15.0-I15.9 for hypertension, I50.1-I50.9 for heart failure, plus obstetric variants O10.011-O16.9/O24.011-O24.93). Failure to implement these controls will result in systematic claim denials from Aetna.