idea-004 · business case

Who pays, from which budget, how much, and 2-4 commercial routes to first revenue — every figure below traces to a copied claim or a declared assumption, and the routes are laid out unranked. Choosing a commercial strategy is a Tier 3 act, so this page presents options and stops.

Home-use wearable LED phototherapy system with onboard irradiance dosimetry for outpatient neonatal hyperbilirubinemia, coded to E0202 — business case

Intended use: For use in the home under prescription to deliver phototherapy to newborns of at least 35 weeks gestational age with uncomplicated indirect hyperbilirubinemia whose total serum bilirubin is above the phototherapy threshold but below the escalation-of-care threshold, as an alternative to inpatient readmission for phototherapy.

Who pays

There are two cheques in this chain, written by different people for different things: the party that buys the device is not the party that pays for the therapy, and the second one sets the ceiling on the first. What changed since the last build is that the code and its Medicare rate are now on the record. What did not change is that neither of them belongs to the payer this population actually has.

Writes the cheque (for the device): the DME (durable medical equipment) supplier who rents the unit to the family and bills the payer, not the hospital, the pediatric practice or the family claim 22unconfirmed. adoption returns unverifiable on that line and the domain dossier records that no source located names the actual US purchaser of a home phototherapy unit. The first link in the chain is still an assumption.
Writes the cheque (for the therapy): a state Medicaid program or a commercial plan. Newborns are not Medicare beneficiaries claim 6unconfirmed, so the Medicare DMEPOS (durable medical equipment, prosthetics, orthotics and supplies) rate now verified for E0202 (a HCPCS code for durable medical equipment) claim 5verified is a rate paid by a payer with no exposure to this population. One state Medicaid program is on record paying E0202 claim 44unconfirmed; whether the largest birth states publish a coverage policy is open claim 23unconfirmed; and whether Medicaid rather than commercial rates set the effective price is open claim 63unconfirmed.
Out of which budget line: the supplier's rental-fleet capital, recovered through a payer allowable. **Which code carries that allowable is now the first open question, not a settled one.** E0202 exists and is the only phototherapy-light code in the Level II file claim 3verified, and its descriptor names a photometer claim 4verified. But the same file carries S9098 (a HCPCS temporary national code), a per-diem home phototherapy service code claim 4verified, and its descriptor (read this build via hcpcs S9098) bundles equipment rental with nursing services and blood draw. If the payers that matter pay home phototherapy under S9098 rather than E0202 [assumption A1], the device is not paid for as a device at all: it is a cost inside a home health provider's per-diem, and the buyer becomes that provider rather than a DME supplier.
Against which comparator: the fiberoptic blanket already in supplier fleets (BiliBlanket / neoBLUE lineage), plus two cleared wrap/wearable garments in the same product code claim 47unconfirmed. The closest, SnugLit (K251308 (an FDA 510(k) clearance number)), holds a cleared indication broader than this candidate's: hospital and home, caregiver-administered, with no gestational-age floor and no bilirubin-band ceiling claim 2verified. The comparator is an incumbent plus two recent entrants, one of which already occupies the whole target population.
Stops buying instead: at the supplier, a fleet slot: one wearable displaces one blanket, so this is substitution inside an existing budget, not new spend. At the payer, an inpatient stay or readmission whose purpose is holding the baby under a lamp claim 17unconfirmed. Who captures that avoided stay is not the hospital if the readmission is paid as a per-case DRG [assumption A4], which bears directly on any route that sells to a health system. The published evidence on the displacement points both ways: a US biliblanket cohort found lower readmission with home treatment claim 38unconfirmed, a 2024 meta-analysis found it higher claim 39unconfirmed. No claim in the file gives the dose record a budget line of its own claim 33unconfirmed, claim 57unconfirmed.

Reimbursement path

Six questions, each with its own evidence position and one basis. No score, no tier, no composite. Read the coverage line first, then read the paragraph under it, because the one pillar that rests on a verified claim is the one that decides the least.

#	Question	Finding	Basis
2a	Coding route — Cat I / Cat III / unlisted / HCPCS (Healthcare Common Procedure Coding System) II / none	HCPCS Level II, not CPT (Current Procedural Terminology). E0202 exists, descriptor "Phototherapy (bilirubin) light with photometer", action code N, no termination date claim 3verified. The descriptor names a photometer, so a unit without one does not meet the descriptor text claim 4verified. Two limits the claim itself records: whether "with photometer" is a payment condition rather than descriptor wording is DME MAC (durable medical equipment Medicare administrative contractor) / payer-edit territory the HCPCS file cannot settle, and Level II is national code existence, silent on which code a Medicaid or commercial payer actually pays home phototherapy under. The competing code is S9098, a per-diem service code claim 4verified, and which of the two the payers that matter use is [assumption A1]	claim 3verified
2b	Payment adequacy — does the rate clear a stated cost floor	No cost floor has ever been stated, so the question cannot yet be asked. Medicare's E0202 allowable is $75.86 (AZ) to $89.25 (AL) non-rural, on one RR capped-rental line billed per rental month, with no purchase line claim 5verified; that is Medicare's rate for a population with no Medicare exposure claim 6unconfirmed. The one Medicaid figure is Louisiana's $33.71 (modifier 09) and $30.90 (modifier 07) claim 44unconfirmed, on a billing unit nobody has established claim 51unconfirmed. Whether a monthly-rental payer pays a full month for a 2-4 day episode is [assumption A2]. The floor itself, the supplier's fully-loaded per-episode cost, is unsourced	claim 52unconfirmed
2c	Practice-expense headroom — does the PE portion cover the device	No practice-expense portion on this route, by construction, on the record only as an assumption. E0202 is a DMEPOS code priced on the DMEPOS fee schedule claim 5verified; `rvu E0202 --device-cost` run this build returned no row in the cached PFS (physician fee schedule) RVU (relative value unit) file. That result is written back as a proposition for the Verifier rather than cited as a finding, because this case cannot issue a tag. A PE question would arise only if the device were furnished incident to an office service, which is not this business	[assumption A3]
2d	Site of care & bundling — office/facility differential, DRG or APC packaging	Home, supplier-billed, and the bundling risk is a per-diem, not a DRG. For Medicare the structure is verified: monthly capped rental, title passing after 13 continuous rental months claim 5verified. For the payers that matter, the exposure is that home phototherapy is paid under S9098, whose per-diem bundles equipment with nursing and blood draw, so the device earns nothing separately [assumption A1]. No DRG or APC packages an item dispensed to a home; `drg` and `apc` returned missing-cache `unconfirmed`, a tooling gap. The DRG bites on the comparator instead: the avoided readmission [assumption A4]	[assumption A1]
2e	Coverage — has any payer agreed to pay for this indication	No payer is on record agreeing to cover it. `coverage E0202` returns no policy naming the code in the cached Medicare Billing & Coding Articles export, which the candidate records with its limits (articles only; names-the-code, not is-covered) inside claim 5verified, whose tag is about the fee and not about coverage. Louisiana paying E0202 claim 44unconfirmed is a payment line, not a coverage criterion. Whether the largest birth states publish a coverage policy is open	claim 23unconfirmed
2f	Ex-US pathway — DE NUB/G-DRG, UK NICE (National Institute for Health and Care Excellence)/OPCS-4	Permanently unconfirmed, and not under-researched. `launch_jurisdiction:` is US; no connector reaches a non-US payment system, and no claim in the candidate speaks to one in any direction	— none

Pillars on verified claims: 1/6 · on assumptions: 2 · queued as research: 0

The other three: 2b rests on claim 52unconfirmed, 2e on claim 23unconfirmed, and 2f on nothing. Read the split before the six. The Verifier's most recent pass moved the code, its descriptor and its Medicare fee to verified, and that is real: the three-part test now reads code exists, Medicare allowable exists, no cached Medicare article names it. But the one pillar that rests on a verified claim is 2a, and 2a is code existence. Everything that turns a code into money for this population (a Medicaid or commercial rate on a known unit, a cost floor under it, a coverage policy, and whether the payer pays the equipment code at all) is unconfirmed or assumed. A verified Medicare fee for a newborn device is a verified fact about the wrong payer.

Three distinctions kept apart deliberately:

A code existing is not payment, and payment is not coverage. 2a is verified; 2b's rate is Medicare's and its floor unsourced; 2e has no payer on record. Three findings, three rows.
Packaging pays nothing extra, and here the package is a per-diem. No DRG or APC reaches a home item. The analogous trap is a per-diem service code that swallows the equipment [assumption A1], and the DRG shows up only on the comparator side [assumption A4].
2f is a permanent unconfirmed. An ex-US expansion would start this section over.

Verdicts recorded where a check was run and came back unusable, rather than routed around:

python3 -m connectors rvu E0202 --device-cost 100 --jurisdiction US → refuted — `"No code E0202 in the cached CMS (Centers for Medicare & Medicaid Services) Physician Fee Schedule RVU file. It is not priced under the PFS — it may still be paid under OPPS, the ASC list or DMEPOS, none of which this connector reads."` The device-cost argument was a placeholder with no row to test it against; the result is carried as [assumption A3] for the Verifier, not as a tag.
python3 -m connectors hcpcs S9098 --jurisdiction US → verified (code exists, per-diem, descriptor bundles equipment rental, nursing services, blood draw and supplies); payment S9098 → refuted, no row in the cached CMS payment files; coverage S9098 → refuted, no cached policy names it; procedures S9098 → refuted, no Medicare row. An S-code is a temporary national code for non-Medicare payers, so all three Medicare absences are the expected result and say nothing about Medicaid or commercial use, which is exactly what [assumption A1] asks.
python3 -m connectors drg 794, drg 795, apc E0202, icd P59.9 → **unconfirmed — no local cache** (ms_drg_weights.csv, opps_addendum_b.csv, icd10cm.csv). Build-environment gaps, not findings. MS-DRG is Medicare's grouper in any case; the newborn readmission is paid under state Medicaid groupers no connector reaches.
python3 -m connectors cpt — not run. No CPT code or descriptor carries any part of this case; the route is HCPCS Level II throughout, and no descriptor is reproduced here.

The money model

There is no market model for this candidate (the market-models shelf has no file for it), so this section does not size anything. A size is a chain with its own spec and its own checker, and building one here is the thing docs/commercial-spec.md §5 forbids. The legs the file carries are quoted, unmultiplied, so the next pass can pick them up. The rest of the model is unit economics: what one episode earns and what one fleet unit has to repay.

Line	Figure	Backing
Size leg — US births, the denominator	3,628,934 in 2024	claim 36unconfirmed
Size leg — commensurability of an all-births denominator with a 35-plus-week rate	not established	claim 50unconfirmed
Size leg — share of 35-plus-week newborns who receive phototherapy	8-12%, a Generator figure the dossier could not source	claim 8unconfirmed
Size leg — independent read on the post-discharge slice	1.8% of 148,162 KPNC infants exceeded threshold after discharge	claim 37unconfirmed
Size leg — share of treated newborns home-eligible	25-40%, the Generator's own assumption	claim 9unconfirmed
Which code the paying payers use for home phototherapy	E0202 (device paid) vs S9098 (device inside a per-diem)	[assumption A1]
Medicare allowable for E0202 — for scale only, not this population's payer	$75.86-$89.25 per rental month, RR line only, no purchase line	claim 5verified
Medicaid allowable for E0202, one state	$33.71 (modifier 09) and $30.90 (modifier 07), Louisiana	claim 44unconfirmed
Billing unit of that Medicaid allowable	per day, per month, per episode or purchase — unresolved	claim 51unconfirmed
Whether a monthly-rental payer pays a full month for a short episode	one full month vs prorated	[assumption A2]
Episode length	2-4 days plus setup	claim 10unconfirmed
Whether Medicaid rather than commercial rates set the effective price	not established; the file's "roughly 40%+" Medicaid birth share is itself uncited	claim 63unconfirmed
Supplier's fully-loaded cost per episode (delivery, setup, training, retrieval, reprocessing)	not established	claim 52unconfirmed
Whether any supplier margin survives that cost	asserted, not measured	claim 24unconfirmed
Reprocessing between rental patients, or single-patient BOM (bill of materials)	unresolved on both routes	claim 29unconfirmed
Price a supplier pays per fleet unit	not established	claim 53unconfirmed
Episodes per fleet unit per year (turns)	not established	claim 54unconfirmed
Share of addressable episodes on this device by year 3	not established	claim 55unconfirmed
Gross margin on the device at the fleet price	not established	claim 56unconfirmed
Incremental payment earned by the dose record	none found: one RR line, no dose-record modifier	claim 57unconfirmed

Read the per-episode line before anything else. The revenue one episode earns is a product of three open questions: which code is paid [assumption A1], on what unit claim 51unconfirmed, [assumption A2], and at whose rate claim 63unconfirmed. Between a per-diem that absorbs the device and a full rental month billed for a 2-4 day episode claim 10unconfirmed, the spread is not a margin question but a question of whether a device line exists. The only published economic evidence points nowhere: a 2026 review of 31 studies found none evaluating cost-effectiveness of home phototherapy claim 40unconfirmed.

The two connectors a business case would ordinarily lean on both refuse, and the verdicts go on the page:

python3 -m connectors market "Annual US home phototherapy episodes for newborns of at least 35 weeks with uncomplicated hyperbilirubinemia, priced at the E0202 allowable, form an addressable market for a dosimetry-equipped wearable" → unverifiable — "has no free, authoritative, machine-queryable source. Stays unconfirmed permanently unless a human attaches a licensed report and edits the claim by hand." (market takes no --jurisdiction flag.)
python3 -m connectors adoption "A DME supplier stocking a home phototherapy rental fleet will choose a dosimetry-equipped wearable over the already-cleared SnugLit wearable (K251308)" → unverifiable — "asserts what clinicians, payers, or patients would do. No free, authoritative, machine-queryable source answers that — it needs primary research ... Do NOT substitute a model's own estimate of stakeholder behaviour: a synthetic stakeholder opinion is a fabricated claim." The same line is on the candidate at claim 34unconfirmed.
python3 -m connectors adoption "State Medicaid programs and commercial plans in the largest US birth states pay newborn home phototherapy under S9098 rather than E0202" → unverifiable, same detail. Its connector-suggested proxies are Medicare-shaped and blind here; the real falsifier is a read of four state fee schedules, which is why it is in the register.

procedures E0202 → refuted, no national row in the Medicare DMEPOS utilization release; as the candidate already records, that is a Medicare FFS (fee-for-service) absence for a population with no Medicare exposure, not a zero-volume floor claim 6unconfirmed.

Path to first revenue

First dollar comes from: the first buyer of fleet units, a DME supplier on the file's own assumption claim 22unconfirmed, or a home health provider billing a per-diem if that is how payers pay [assumption A1]. A device sale into a channel, not a reimbursement event.
What must exist first, each attributed:
- 510(k) (premarket notification) clearance under 21 CFR (Title 21 of the Code of Federal Regulations) 880.5700 / LBI claim 1verified, against a predicate pool that is not the constraint claim 2verified, on the untested premise that FDA (US Food and Drug Administration) accepts bench photometric data alone for a narrowed indication plus a dosimetry feature claim 30unconfirmed.
- A radiometer that measures delivered dose at the skin within a defensible tolerance claim 27unconfirmed, across the 1.5-5.5 kg range the cleared analog spans claim 35unconfirmed.
- A billable code: E0202 exists and names a photometer claim 3verified, claim 4verified; at least one payer paying it, still one state on record claim 44unconfirmed.
- A reprocessing or single-patient-BOM answer, without which no rental fleet exists claim 29unconfirmed.
- An FTO (freedom to operate) position: no patent search has been attempted, on the rubric's one automatic-kill factor claim 28unconfirmed.
Calendar to first dollar: 12-24 months claim 16unconfirmed, the file's own estimate for a 510(k) against an LBI predicate, bench testing only, no clinical study claim 16unconfirmed.
Capital to first dollar: low single-digit millions on the same estimate claim 16unconfirmed, which explicitly excludes the go-to-market leg.
Fleet capital before the first billed episode: units × price per unit claim 53unconfirmed, sized by turns claim 54unconfirmed.
Lag from first delivery to first paid claim: not established claim 58unconfirmed.
Channel build and supplier enrollment in the target states: not established claim 59unconfirmed, claim 60unconfirmed; the cleared wearable's maker may already hold the relationships claim 25unconfirmed.

Routes

Four, laid out side by side and not ordered. Choosing among them is a Tier 3 act; this section presents them and stops.

Route A — Sell fleet units to DME suppliers who bill E0202

The file's own model: hardware sold to DME suppliers who rent to families and bill Medicaid or commercial plans under E0202 claim 22unconfirmed.

Requires: 510(k) clearance claim 1verified; payers in the target states paying the equipment code rather than a per-diem [assumption A1]; a known billing unit and rate claim 44unconfirmed, claim 51unconfirmed; a reprocessing answer claim 29unconfirmed; supplier relationships claim 25unconfirmed.
Costs: 12-24 months and low single-digit millions to clearance claim 16unconfirmed, plus channel build claim 59unconfirmed. Revenue per unit rests on price claim 53unconfirmed, turns claim 54unconfirmed and margin claim 56unconfirmed.
Killed by: the supplier's per-episode cost exceeding what E0202 pays per episode on the applicable unit — claim 52unconfirmed resolving false. If renting it loses money, the channel does not stock it.

Route B — Own the home service and bill the per-diem

Vertically integrated: enrol as the provider, deliver and set up the device, train parents, and bill payers for the episode, under S9098 where that is what payers pay [assumption A1] or under E0202 where it is not. Treats the file's premise that the binding constraint is the service model claim 13unconfirmed as the thing to own.

Requires: supplier and per-state Medicaid enrollment claim 60unconfirmed; a coverage pathway in the target states claim 23unconfirmed; prior authorization inside the clinical window claim 67unconfirmed; family out-of-pocket exposure low enough that episodes are not declined claim 21unconfirmed.
Costs: clearance as in Route A claim 16unconfirmed; fleet on its own balance sheet claim 53unconfirmed; per-episode service delivery claim 52unconfirmed; the claims-cycle lag claim 58unconfirmed.
Killed by: the largest birth states publishing no coverage pathway for newborn home phototherapy under either code — claim 23unconfirmed resolving false. There is then nothing to bill, and no hardware-sale fallback.

Route C — License the dosimetry subsystem into an already-cleared wearable

Ship the differentiator, not the garment: an OEM radiometer and dose-record module into a cleared LBI wearable, neither of which claims dosimetry claim 2verified, claim 47unconfirmed.

Requires: the module qualifying without a new full 510(k) for the host claim 61unconfirmed; a radiometer validated as a module claim 27unconfirmed across the size range claim 35unconfirmed; an FTO position on integrated dosimetry claim 28unconfirmed; a partner who values the record claim 12unconfirmed.
Costs: no fleet and no channel build; module validation and regulatory scoping against the same clearance baseline claim 16unconfirmed. Revenue is a royalty or transfer price set by the partner, so the device-price lines claim 53unconfirmed, claim 56unconfirmed are replaced rather than answered.
Killed by: bench data showing sensor-to-skin geometry does not hold across the size range, so a logged dose is not comparable between patients — claim 35unconfirmed resolving false.

Route D — Sell the dose record to payers or risk-bearing health systems

Bypass the rental channel: contract with whoever bears the cost of the avoided readmission, and the device travels with the record. Under per-case DRG payment that party is the payer or a capitated system, not a fee-for-service hospital [assumption A4].

Requires: a US readmission differential attributable to home phototherapy with a dose record; clinicians substituting home for inpatient treatment without home bilirubin measurement claim 19unconfirmed; clinicians acting on the record claim 33unconfirmed, in a population where 24% of surveyed US birthing hospitals obtained the guideline's post-discontinuation check claim 45unconfirmed.
Costs: a US comparative study claim 62unconfirmed, benchmarked against the one registered US trial here, which enrolled 72 and posted no results claim 48unconfirmed; on top of clearance claim 16unconfirmed.
Killed by: a US comparative study showing no readmission advantage for home phototherapy with a dose record. The pooled non-US base already points that way, at 4.61x higher readmission claim 39unconfirmed, and the one wearable pilot switched 2 of 12 neonates to intensive phototherapy claim 41unconfirmed.

Assumption register

Four new assumptions, each written back to the candidate as unverified (claims 68-71). The fourteen assumptions the 2026-09-03 build declared are already on the candidate as claims 50-63, each attempted by the Verifier on 2026-09-29 and tagged unconfirmed; this rebuild cites them as claims rather than re-declaring them, because re-appending them would duplicate lines the Verifier has already worked.

#	Assumption	Falsifier	Owner
A1	State Medicaid programs and commercial plans in the largest US birth states pay newborn home phototherapy predominantly under the per-diem service code S9098, which bundles equipment rental with nursing and blood draw, rather than under the equipment code E0202 (claim 68unverified)	Read the current DMEPOS and home-health fee schedules of the California, Texas, Florida and New York Medicaid programs for E0202 and S9098 lines, and the home-phototherapy medical policies of the two largest commercial plans in each; revealed-behaviour twin: which code an operating home-phototherapy provider actually bills in each state	Reimbursement analyst
A2	A payer that prices E0202 as a monthly rental pays one full rental month's allowable for a home phototherapy episode of 2-4 days, rather than a prorated or per-day amount (claim 69unverified)	The DME MAC supplier manual rule on rental-month billing for capped-rental items, plus the rental-unit definition in each target state's Medicaid DMEPOS provider manual	Reimbursement analyst
A3	HCPCS E0202 has no row in the CMS Physician Fee Schedule RVU file, so no practice-expense RVU carries the cost of a device billed under it (claim 70unverified)	`python3 -m connectors rvu E0202 --jurisdiction US` against the cached PFS RVU file, re-run by the Verifier	Verifier
A4	A newborn phototherapy readmission is paid to the hospital as a per-case DRG by state Medicaid programs and most commercial plans, so the avoided cost accrues to the payer, not the hospital, outside capitated or value-based contracts (claim 71unverified)	The inpatient payment method (APR-DRG or other) in the target states' Medicaid hospital payment manuals, plus a commercial contract template or a health system's payer-mix disclosure on newborn admissions	Reimbursement analyst

Where this case outruns the file

Every figure with no evidence behind it, gathered as work items.

Any size at all. No market model exists; this case quotes five legs and multiplies none of them. /market-model idea-004 is the cheaper next pass: it is the only process in the repo that will file the missing legs as research rather than restate them.
Which code pays (A1). The difference between E0202 and a per-diem is whether this device has a revenue line of its own, and nothing in the file speaks to it.
Revenue per episode (A2, and claims 51 and 63). The file carries two rates on two payers and no unit for the one that matters.
The device P&L (claims 52-56). Supplier cost, unit price, turns, share and margin: all declared in the last build, all unconfirmed on the Verifier's attempt, none moved.
Whether the dose record is paid for (claim 57unconfirmed). The moat rests on it claim 12unconfirmed; the only Medicare line carries no modifier for it.
Who captures the avoided readmission (A4). Route D stands on it.
Every go-to-market cost (claims 58-60) sits outside the file's own capital estimate claim 16unconfirmed, which covers the 510(k) and excludes the rest.

Words on this page18 abbreviation(s) and code(s), with what each stands for — copied from _shared/plain-language.md

21 CFR: Title 21 of the Code of Federal Regulations — the US food-and-drug rulebook; a number after it is one regulation, often the one that classifies a device type
510(k): premarket notification — the FDA route for a device shown to be as safe and effective as one already on the market; months, no clinical trial as a rule
BOM: bill of materials — the list of parts in a product and what each costs
CMS: Centers for Medicare & Medicaid Services — the US agency that runs Medicare, and so decides what Medicare pays for
CPT: Current Procedural Terminology — the US billing codes for what a clinician does; owned by the American Medical Association
DME: durable medical equipment — equipment a patient uses at home, such as a pump or a stimulator, that Medicare pays for under its own rules
DME MAC: durable medical equipment Medicare administrative contractor — one of the four regional contractors that process Medicare's home-equipment claims and write its local coverage rules
DMEPOS: durable medical equipment, prosthetics, orthotics and supplies — the Medicare benefit and fee schedule that home equipment is paid under
E####: a HCPCS code for durable medical equipment — one billing code for a piece of home equipment; the letter E and four digits
FDA: US Food and Drug Administration — the US regulator that clears or approves a device before it can be sold
FFS: fee-for-service — the traditional form of Medicare that pays per item or service
FTO: freedom to operate — whether a product can be sold without infringing someone else's live patent
HCPCS: Healthcare Common Procedure Coding System — the US billing codes for equipment, supplies and some services; a code is how a payer recognises what to pay for
K######: an FDA 510(k) clearance number — the public record of one cleared device; the letter K and six digits
NICE: National Institute for Health and Care Excellence — the English body whose guidelines say what the NHS should use
PFS: physician fee schedule — the Medicare price list for what clinicians do
RVU: relative value unit — the unit Medicare uses to price a clinician's work
S####: a HCPCS temporary national code — a billing code used by some private payers and not by Medicare

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