AOA Scores Win: Aetna and Humana End Auto‑Downcoding for Optometrists

A long overdue win for the Optometry Community is in sight!

In a major victory for optometrists nationwide, the American Optometric Association (AOA) has secured commitments from two major insurers—Aetna and Humana—to end certain automatic downcoding practices that have been impacting fair reimbursement for eye care services.

This move follows months of sustained advocacy and engagement by the AOA and its Third Party Center, and represents a significant step forward in the ongoing fight against unfair insurance coding practices.

What Is Auto‑Downcoding—and Why Is It a Problem?

Auto-downcoding is the practice by which insurers automatically reduce higher-level billing codes (often used for more complex exams or medical decision-making) to lower-cost codes without reviewing the patient record. This can result in lower reimbursement—even when the care provided justified the original billing level.

While used across various specialties, optometrists have increasingly found themselves caught in these automated edits, particularly when using the 92xxx and 99xxx code sets for evaluation and management (E/M) services.

What’s Changing?

Thanks to AOA advocacy, Aetna and Humana have now changed course to protect optometrists:

✅ Humana

• As of August 24, 2025, Humana removed optometrists from its automatic downcoding program for 99xxx E/M codes.

• Notably, Humana had never auto‑downcoded the 92xxx codes for optometrists.

  
  

✅ Aetna

• Effective September 28, 2025, Aetna has stopped auto‑downcoding 92xxx codes for optometrists.

• Aetna may still downcode 99xxx “billing outliers”—a policy that applies broadly across specialties, not just optometry.

If you experienced downcoded claims before these effective dates, the AOA urges you to file appeals and report cases to stopplanabuses@aoa.org.

Cigna’s New Downcoding Policy

While progress has been made with Aetna and Humana, Cigna has gone in the opposite direction.

Starting October 1, 2025, Cigna implemented a new downcoding initiative, targeting level 4 and 5 E/M codes—especially for conditions like sore throat, cough, or earache. The AOA is already in talks with Cigna’s medical directors and is monitoring the impact on optometry practices.

AOA leadership believes few optometrists will be affected but encourages providers to appeal any improperly downcoded claims and report them promptly.

Protect Your Practice: Documentation Is Your Best Defense

Whether or not your claims have been downcoded, maintaining strong clinical documentation is your best defense—and key to successful appeals.

AOA’s Top Documentation Tips:

1. Be specific and detailed – Clearly describe symptom severity, onset, duration, and impact.

2. Support medical necessity – Explain why the service was required for that patient on that day.

3. Align codes with documentation – Ensure your CPT and ICD‑10 codes reflect your notes and findings.

4. Avoid ambiguity – Use clear, consistent language that tells a cohesive clinical story.

5. Include complete EHR documentation – Don’t leave out relevant sections when submitting claims or appeals.

   
   

Your patient record should include:

• Patient demographics

• Provider name and date of service

• Medical history and social determinants of health

• Chief complaint and expanded HPI

• Exam findings and test results

• Diagnosis and treatment plan

• Medication orders and referrals

• Matching CPT and ICD‑10 codes

  
  

Final Thoughts

This progress with Aetna and Humana marks a critical win for optometrists and fair reimbursement practices. But the work isn’t over. The AOA continues to advocate against all forms of automatic downcoding and encourages ODs to remain proactive in reviewing their claims and documentation.

If you suspect improper coding edits from any payer, don’t stay silent—file an appeal and report it to the AOA at stopplanabuses@aoa.org.

💡 Tip: Consider joining AOA’s advocacy efforts to help shape the future of fair optometric care.