Insurance Advocacy

The ACR is working to ensure that insurance policies impacting coverage and payment for rheumatology services are fair and appropriate. The volunteer members of the ACR Insurance Subcommittee help lead this effort by educating payers and advocating for policies that prioritize access to rheumatology care and treatment. Below are updates and resources on key insurance advocacy priorities and information on requesting assistance with an insurance concern.

Insurance Issues

See resources to help with insurance grievances, complaints, and denials.

Medicare Contractor Directory

Downcoding Level 4 and 5 Evaluation and Management (E/M) Claims

Several commercial payers, including Aetna and Cigna, have recently implemented policies subjecting claims billed with Current Procedural Terminology (CPT) evaluation and management (E/M) codes 99204-99205, 99214-99215, and 99244-99245 to additional scrutiny. These policies may result in some claims being automatically adjusted and paid at a level lower than originally billed. The ACR has engaged with payers to advocate against the inappropriate reduction of payment for rheumatology services and increased administrative burden for practices to appeal these downcoded claims. Additionally, ACR recognizes that health insurance payers are increasingly using artificial intelligence to review claims and has implored these payers to ensure integrity in claims processing by employing professional coders.

ACR Letter to Cigna – E/M Downcoding (July 2025)

Rheumatology Sign-on Letter to Cigna – E/M Downcoding (September 2025)

Formulary Requirements and Reimbursement for Biosimilars

Numerous payer formularies require patients to use certain biosimilar therapies, despite reimbursement falling below acquisition costs for many independently owned rheumatology practices. The ACR is engaging with both commercial payers and CMS regarding these formulary requirements that would leave many practices underwater. The ACR supports biosimilar use and is encouraged by their overall impact on reducing drug costs; however, requiring practices to infuse any drug at a loss undermines financial solvency and is unacceptable.

New Fact Sheet: Underwater Biosimilars

Members Only Resources

Template Payer Letter for Practices: Formulary Exception for Underwater Drugs

Prior Authorization Requirements for Mandated Switches to a Biosimilar

Many health plans have implemented policies that require rheumatology patients to switch from an originator drug to a biosimilar. In addition to mandating the switch, they are also requiring the practice to complete a new prior authorization for the drug. These changes are impacting numerous patients within a practice which is causing significant administrative burden, particularly in cases where the payer requests additional medical records. The ACR continues to advocate for a more streamlined process which would help alleviate the burden on practices and ensure timely and uninterrupted access to treatment.

Members Only Resources

Template Payer Letter for Practices: Opposing Required Biosimilar Switch

Template Payer Letter for Practices: Returning to Originator Drug After Biosimilar Switch

Specialty Pharmacy Acquisition Requirements

Commercial insurance companies and pharmacy benefit managers (PBMs) have implemented policies mandating that in-office treatments be purchased through specialty pharmacies instead of the traditional “buy-and-bill” system. In some cases, employers are being given the choice to include these requirements as part of their employee health plan without fully understanding the impact on patient care and access to treatment. The ACR is committed to ongoing stakeholder education and advocacy efforts to oppose these policies that threaten patients’ access to critical in-office treatments.

Fact Sheet: Protect Access to Physician-Administered Therapies

ACR Letter to Aetna – Combined Benefit Management Drug List (May 2025)

Members Only Resources

Letter Template - Practice to Patient Employer: Protect Access to Physician Administered Therapies

Tools & Resources for ACR Members

These template letters can be used to help secure insurance approval for off-label uses frequently seen in rheumatology practices.

Off-Label Drug Use Letters

Adalimumab – Refractory Sarcoidosis

Adalimumab – Sarcoidosis

Apremilast – Combination Therapy

Infliximab – Refractory Sarcoidosis

Infliximab – Uveitis

Rituximab – Lupus Nephritis

Rituximab – Myositis

Rituximab – Scleroderma

Rituximab – Severe SLE

Sildenafil – Refractory Ulcerative Raynaud's Phenomenon

Pediatric Letters

Anakinra – Macrophage Activation Syndrome (MAS)

Biologics – Relapsing Chondritis (RP)

Infliximab – Sarcoidosis

MRI – Temporomandibular Joint (TMJ) Arthrtitis

Rituximab and Cytoxan – CNS Lupus

Sildenafil – Refractory Ulcerative Raynaud's Phenomenon