FACTORS ASSOCIATED WITH REPEAT HCPCS REVIEW CYCLES AMONG EMERGING MEDICAL TECHNOLOGIES
Author(s)
Ali Samiian, BA, MBA, MSc, JD1, Erin Margaret Falvey, BS2, Eric Greig, JD3.
1Managing Principal and Founder, Poplar Access Advisors, San Mateo, CA, USA, 2Poplar Access Advisors, South San Francisco, CA, USA, 3Cooley LLP, Washington, DC, USA.
1Managing Principal and Founder, Poplar Access Advisors, San Mateo, CA, USA, 2Poplar Access Advisors, South San Francisco, CA, USA, 3Cooley LLP, Washington, DC, USA.
OBJECTIVES: Healthcare Common Procedure Coding System (HCPCS) applications for emerging medical technologies frequently undergo multiple review cycles before coding, benefit category, or payment determinations are finalized. While HCPCS outcomes have been extensively described, less is known about factors associated with repeat review. This analysis evaluated technologies reviewed across multiple HCPCS Workgroup cycles to identify recurring reimbursement challenges associated with delayed determinations.
METHODS: The authors developed a structured longitudinal database from HCPCS Application Summaries / Final Determinations published between 2019 and 2025. Technologies appearing in multiple review cycles were consolidated into a single product record to avoid double counting of devices, supplies, and related applications. Each product was evaluated for coding, benefit category, payment/pricing, durability, software-hardware integration, clinical distinction, setting of use, supplies/accessories, bundling, and other factors contributing to repeat review.
RESULTS: 53 technologies underwent review in multiple HCPCS cycles. The mean number of review cycles was 2.4, with a median of 2.0 and a maximum of 4 cycles. Mean time from first review to final determination was 19.7 months, with a median of 18.0 months and a maximum of 54 months. Benefit category issues were the most common contributing factor, affecting 33 technologies (62.3%), followed by coding-related issues (54.7%), payment/pricing considerations (47.2%), and clinical distinction from existing technologies (32.1%). Durability or useful life requirements affected 15.1% of technologies but were associated with the longest average review timeline (25.5 months). Payment/pricing issues averaged 21.0 months, benefit category issues averaged 20.8 months, and software-hardware integration issues averaged 17.0 months.
CONCLUSIONS: Repeat HCPCS review cycles appear to be driven by multifactor reimbursement considerations extending beyond coding alone. Benefit category determination, payment methodology, clinical differentiation, and technology configuration were frequently associated with repeated review among emerging medical technologies. Early identification of these factors may reduce reimbursement uncertainty and improve the efficiency of coding, payment, and coverage pathway development.
METHODS: The authors developed a structured longitudinal database from HCPCS Application Summaries / Final Determinations published between 2019 and 2025. Technologies appearing in multiple review cycles were consolidated into a single product record to avoid double counting of devices, supplies, and related applications. Each product was evaluated for coding, benefit category, payment/pricing, durability, software-hardware integration, clinical distinction, setting of use, supplies/accessories, bundling, and other factors contributing to repeat review.
RESULTS: 53 technologies underwent review in multiple HCPCS cycles. The mean number of review cycles was 2.4, with a median of 2.0 and a maximum of 4 cycles. Mean time from first review to final determination was 19.7 months, with a median of 18.0 months and a maximum of 54 months. Benefit category issues were the most common contributing factor, affecting 33 technologies (62.3%), followed by coding-related issues (54.7%), payment/pricing considerations (47.2%), and clinical distinction from existing technologies (32.1%). Durability or useful life requirements affected 15.1% of technologies but were associated with the longest average review timeline (25.5 months). Payment/pricing issues averaged 21.0 months, benefit category issues averaged 20.8 months, and software-hardware integration issues averaged 17.0 months.
CONCLUSIONS: Repeat HCPCS review cycles appear to be driven by multifactor reimbursement considerations extending beyond coding alone. Benefit category determination, payment methodology, clinical differentiation, and technology configuration were frequently associated with repeated review among emerging medical technologies. Early identification of these factors may reduce reimbursement uncertainty and improve the efficiency of coding, payment, and coverage pathway development.
Conference/Value in Health Info
2026-11, ISPOR Europe 2026, Vienna, Austria
Value in Health, Volume 29, Issue 12S
Code
HPR200
Topic
Health Policy & Regulatory, Health Technology Assessment, Medical Technologies
Topic Subcategory
Pricing Policy & Schemes, Reimbursement & Access Policy
Disease
No Additional Disease & Conditions/Specialized Treatment Areas