AMA CPT was in the spotlight in mid-July, when CMS released a "request for information" that was highly concerned about both the AMA CPT (coding) and AMA RUC (valuation). Entry point from my blog at the time, here.
Now, headlines that the "Patient Rights Advocate" organization has sued AMA over the CPT "monopoly" (so called). Find PRA here, find the legal case here, find news at Fierce Healthcare here.
Here's a summary:
- PatientRightsAdvocate.org has sued the AMA in federal court, seeking authority to publish CPT freely online. The 25-page complaint argues that CPT cannot remain privately controlled because federal and state governments have incorporated it into law and require its use across Medicare, Medicaid, HIPAA transactions, and much of healthcare billing. Alternatively, PRA argues that free nonprofit publication is fair use and that AMA’s copyright remains unenforceable because of earlier copyright misuse.
- The case arrives only a month after CMS, in its July 2026 Physician Fee Schedule RFI, explicitly questioned AMA’s CPT licensing monopoly and the related CPT/RUC payment processes.
- Sen. Bill Cassidy has separately attacked the “government-backed monopoly” and licensing fees.
- Both developments were reported unusually quickly and prominently by Dan Diamond at the Washington Post.
- A sweeping invalidation of CPT copyright is uncertain, but narrower victories—especially fair use, mandated free access, or revised federal licensing—appear considerably more plausible.
AI CORNER
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AMA’s CPT Monopoly Goes to Court: Patient Rights Advocate Takes Its Case to a Federal Judge
Header: One month after CMS asked whether the AMA has too much control over CPT and the RUC, PatientRightsAdvocate.org asks a more fundamental question: Can the AMA copyright—and charge for—codes that the government requires everyone to use?
There is suddenly a remarkable amount of pressure on what had long seemed one of the immovable pieces of the American health care system: the American Medical Association’s ownership and licensing of Current Procedural Terminology (CPT).
In mid-July, CMS used the 2027 Physician Fee Schedule proposed rule to ask unusually pointed questions about the AMA’s role in both CPT coding and physician payment valuation through the RUC. CMS explicitly asked about the “harms or challenges” created by the AMA’s monopoly over CPT-4 licenses, whether there are alternatives to CPT, and whether there are more objective alternatives to the present AMA/CPT/RUC processes.
I wrote about that episode here in July under the headline “WaPo Jumps on CMS RFI Against AMA CPT, RUC.” One striking feature was how rapidly the story reached the Washington Post: Dan Diamond had a major article almost as soon as the obscure policy proposal surfaced, including administration discussion of alternatives to the AMA “monopoly.”
Now, barely a month later, the second shoe has dropped.
On August 13, PatientRightsAdvocate.org (PRA) filed suit against the AMA in federal court in Chicago. The actual complaint is a compact but remarkably ambitious 25 pages. PRA has bought a copy of the 2026 CPT book and says it wants to scan the entire book, put it online in a searchable format, and let anyone use it for free. It has deliberately not done so yet. Instead, it is asking a federal judge to declare that doing so would not infringe an enforceable AMA copyright.
This is not just a press-release complaint about high licensing fees. The pleading is carefully constructed around three separate bodies of copyright law, and there are some surprisingly serious precedents behind it.
First, What PRA Is—and Is Not—Suing About
The word “monopoly” appears repeatedly in the political debate, but it is worth being precise. This is not an antitrust lawsuit seeking damages or the breakup of the AMA. Nor is PRA suing the RUC.
It is a declaratory-judgment copyright case.
PRA asks the court for several related declarations: that its proposed publication of CPT would not infringe copyright; that the AMA’s asserted copyrights are invalid; alternatively, that PRA’s publication would constitute fair use; and alternatively again, that the copyrights are presently unenforceable because of copyright misuse.
The RUC connection is political and regulatory rather than part of the complaint’s causes of action. CMS’s July RFI grouped together two separate but interconnected centers of AMA influence: CPT largely determines what service is being described and billed, while the RUC supplies recommendations that help determine the relative resources and values attached to physician services. CMS is now questioning both systems. PRA’s lawsuit attacks only the CPT ownership and licensing side.
That distinction actually makes the lawsuit more interesting. The government is simultaneously reconsidering its dependence on the AMA from one direction, while a private plaintiff is attacking the legal foundation of CPT exclusivity from another.
The Complaint Begins With a Peculiar Fact About CPT
CPT is private intellectual property—but it is private intellectual property that the government has made extraordinarily difficult to avoid.
The AMA first published CPT in 1966, with CPT-4 appearing in 1977. It now produces an annual revision, and the AMA registers copyright in each edition.
But CPT is not merely a successful commercial reference book.
Congress directed the predecessor of CMS, HCFA, to establish a uniform procedure coding system. HCFA subsequently developed HCPCS, with Level I consisting of the CPT codes in their entirety and Level II consisting primarily of codes developed by the government for other products and services. In 1983, HCFA and the AMA signed a licensing agreement under which HCFA agreed to adopt and use CPT-4 within HCPCS.
That agreement went surprisingly far. The complaint reproduces provisions under which HCFA would publicly endorse CPT, use it in federal programs where possible, and—as originally written—not use a competing physician procedure nomenclature. The federal government received a royalty-free license, but CPT remained AMA copyrighted material.
There was also substantial governmental participation in CPT governance. Under the original arrangement, HCFA could nominate a voting member of the CPT Editorial Panel; a CMS representative apparently retained voting status until at least 2018. CMS, CDC and FDA representatives today remain nonvoting liaisons who, according to the AMA itself, have significant opportunity to participate in panel review.
Then HIPAA made the relationship still more consequential.
HHS regulations adopted CPT as a standard medical data code set for physician and other health services in electronic transactions. The complaint emphasizes an unusual feature: the regulation points not simply to a frozen historical edition, but to CPT as maintained and distributed by the AMA.
PRA makes a great deal of this. Its argument is that the government has effectively allowed a private organization to change portions of a federally mandated coding standard prospectively through the AMA’s annual CPT process.
Meanwhile, according to the complaint, at least 45 states require CPT in various reimbursement or reporting contexts, and at least 15 expressly incorporate CPT by reference into law or regulation.
Thus PRA’s basic rhetorical question practically writes itself:
At what point does a privately created standard become so thoroughly embedded in mandatory public law that the copyright owner can no longer stop the public from reading and reproducing it?
There Is Also a Lot of Money Here
The complaint is not shy about the economics.
It says an individual copy of the 2026 CPT Professional Edition costs $137.89. The cited standard electronic licensing arrangement includes an annual charge plus a per-user fee, and health plans can be charged on a per-member basis.
More dramatically, the AMA reported $296.4 million in 2025 revenue from “Books and Digital Content,” with $267.5 million remaining after expenses in that category. PRA alleges, “upon information and belief,” that CPT licenses and sales account for the overwhelming majority of that business. That last point is an allegation in the complaint, not a separately established fact.
The Washington Post separately reports recent data putting annual CPT royalties above $300 million.
One can therefore understand why this is not a casual intellectual-property dispute. A broad PRA victory could potentially disrupt a very large AMA revenue stream.
Count I: “No One Can Own the Law”
PRA’s first and most sweeping claim is that the relevant CPT copyrights are simply invalid.
The complaint actually offers three theories for getting there.
First, PRA invokes the “government edicts doctrine.” The Supreme Court’s 2020 Georgia v. Public.Resource.Org decision famously rests on the principle that judges and legislators acting with authority to make or interpret law cannot themselves be copyright “authors.” PRA attempts to extend that doctrine to the AMA by arguing that the government has delegated sufficient lawmaking authority to the AMA that annual CPT changes effectively carry the force of law.
That is clever—but not automatic.
The Supreme Court in Georgia emphasized who authored the material and in what official capacity, rather than announcing a simple rule that everything incorporated into law automatically loses copyright protection. The AMA can therefore answer: We are a private organization. We wrote CPT. Government later chose to use it.
PRA responds that CPT is an unusually extreme case because the government did much more than later cite a private book: CMS participated in CPT governance, signed a continuing agreement to use it, and HIPAA dynamically accepts future AMA revisions.
That may make this an interesting test of where “private standard setter” ends and “delegated lawmaker” begins.
PRA’s second theory is more direct: once CPT was incorporated into statutes and regulations, those incorporated provisions became law and entered the public domain. The complaint relies heavily on cases involving model building codes and technical standards, including Veeck and the Fifth Circuit’s recent Canadian Standards Association decision.
And third, PRA argues that parts of CPT may independently be uncopyrightable because the federal government helped author them. CMS had a voting representative on the Editorial Panel for decades, and PRA alleges that government representatives proposed language and codes that became part of CPT. If proven, this theory might at least produce a partial public-domain result, even if the court refused to invalidate CPT wholesale.
But There Is a 1997 Problem for PRA
One of the most interesting things about the complaint is that the famous 1997 case it cites as a weapon against the AMA is also one of the AMA’s best weapons against PRA.
In Practice Management Information Corp. v. AMA, the Ninth Circuit considered CPT itself.
The court did indeed hold that the AMA had misused its copyright through its agreement requiring HCFA not to use a competing coding system.
But the Ninth Circuit also affirmed the validity of the CPT copyright, rejecting the argument that governmental use of CPT had itself caused the copyright to disappear. The Justice Department’s contemporaneous Supreme Court filing describes the decision in exactly those two parts: CPT remained copyrighted, but the exclusivity arrangement constituted misuse.
So PRA cannot simply say, “There was already a CPT case and AMA lost.”
AMA lost one important issue and won another.
PRA’s response will be that the law has developed considerably since 1997—Veeck, Georgia, the modern technical-standards cases, and especially the recent wave of litigation over putting incorporated standards online. Also, the present complaint alleges a much denser degree of legal incorporation and governmental participation than the older case may have confronted.
Still, Practice Management makes a sweeping judicial declaration that “all CPT is uncopyrightable” considerably harder than the complaint’s rhetoric might initially suggest.
Count II: Fair Use May Be PRA’s Best Route
The second count may ultimately be the most dangerous one for the AMA.
PRA says: even if AMA owns perfectly valid CPT copyrights, our particular use of CPT—posting it free so the public can read the rules it is legally required to use—is fair use.
That avoids the need for a judge to declare the AMA’s intellectual property invalid for everyone and for every purpose.
Recent precedent is increasingly favorable to exactly this argument.
The D.C. Circuit has held that nonprofit dissemination of technical standards incorporated into law can qualify as fair use. Even more strikingly, in April 2026 the Third Circuit affirmed denial of a preliminary injunction against UpCodes, finding the company likely to succeed on fair use when it published incorporated technical standards online. The court found that the public-access purpose, factual and legally incorporated nature of the material, and even copying the entirety of the standards could favor fair use.
PRA has almost designed its proposed conduct around that case law.
It is a nonprofit. It says it will charge nothing. It wants to make the material searchable for public understanding rather than sell a rival coding system. And it argues that reproducing the entire work is necessary precisely because governments have given legal effect to the entire coding system.
The complaint even confronts the obvious fourth-factor problem: wouldn't a free CPT website destroy part of the AMA’s existing market?
Possibly.
But PRA argues that the relevant market value is largely created by legal compulsion in the first place. It also argues that physicians and their trade organizations would have powerful non-copyright incentives to keep a standardized payment vocabulary functioning even if the public could read it for free.
The AMA has an equally obvious response: PRA is not quoting a few codes for commentary; it proposes to put a searchable substitute for the entire commercial product online for nothing. That looks like severe market substitution, and the AMA will argue that copyright revenue finances the continuous editorial work necessary to maintain CPT.
Indeed, in responding publicly to the new suit, the AMA says CPT is continuously updated through an open collaborative process involving medicine, government and industry, and says it will vigorously defend its intellectual-property rights.
Nevertheless, if I were ranking PRA’s routes to a meaningful victory, fair use would be first.
A court could rule for PRA on fair use without having to detonate the entire CPT copyright structure.
Count III: The AMA’s 1997 Copyright-Misuse Boomerang
The third claim brings back Practice Management.
The 1983 HCFA agreement said that HCFA would use CPT and would not use another physician procedure nomenclature. In 1997, the Ninth Circuit held that conditioning the CPT license on the government’s promise not to use competing products went beyond the proper scope of copyright and constituted copyright misuse.
The AMA subsequently renounced the offending exclusivity provision.
PRA says that was not enough.
Why? Because, it argues, CMS documentation still states that CMS “shall adopt and use CPT-4” for Medicare and Medicaid, and because forty years of building the American billing system around CPT created enormous network effects and sunk costs. Even if the original “no competitors” sentence vanished, PRA argues, the practical consequences of the misuse never did.
This is an ingenious argument, but it may be more fact-dependent than PRA’s fair-use claim.
The federal government itself told the Supreme Court in the old litigation that the AMA’s renunciation of the exclusivity provision might substantially purge the misuse and limit the practical consequences of the Ninth Circuit ruling.
On the other hand, this case is being litigated in the Seventh Circuit, where the court has itself expressed hostility to attempts to stretch copyright to block access to material the copyright does not properly cover. In Assessment Technologies v. WIREdata, the Seventh Circuit suggested that using copyright litigation to obtain protection that copyright law does not confer can amount to misuse.
This count may therefore become unusually dependent on discovery: What exactly does the current AMA-CMS agreement say? What has changed since 1983? How easily could CMS adopt a competing system today? And how much of CPT's present dominance stems from a government mandate rather than ordinary market choice?
Those could be very interesting documents and depositions.
PRA Has Also Thought Carefully About Standing
PRA has not committed the act the AMA would call infringement.
That is deliberate.
It bought the 2026 CPT Professional Edition from a third-party seller. It did not assent to an AMA license when it bought the book. It says it is prepared immediately to scan and publish the book if the court declares that lawful, and it plans to buy and do the same thing with future annual editions. Until then, it has refrained from copying anything.
The complaint then builds a record showing why PRA reasonably expects AMA enforcement: AMA publicly requires licenses for entities using or displaying CPT content; AMA has previously litigated to defend CPT; and, very recently, AMA filed an amicus brief in the UpCodes litigation specifically defending the enforceability of CPT copyright and opposing free online publication of incorporated standards.
There is even a rehearsal underway in the same federal district. PRA has been trying to make the UB-04 Data Specifications Manual freely available on similar grounds, and the American Hospital Association sued PRA over that effort in late 2025.
Thus PRA is not asking the court for an abstract law-school opinion. It has a book, a defined plan, an asserted copyright blocking that plan, and substantial reason to expect litigation if it acts first.
So, What Are the Chances?
This does not strike the reader as a publicity lawsuit destined for immediate dismissal. There are real cases on both sides, and some of the most important pro-public-access precedents are quite recent.
But there is a large difference between a PRA victory and PRA winning everything it asks for.
A maximal ruling—the AMA’s CPT copyrights as a whole are invalid and CPT is simply public domain—looks substantially harder. The old Practice Management decision points the other way on CPT itself, while the Supreme Court’s Georgia opinion does not mechanically convert every privately written standard referenced by government into a government work.
PRA's novel delegated-lawmaker theory may change that equation, particularly because HIPAA dynamically incorporates AMA-maintained CPT and because government officials historically participated in the Editorial Panel. But that is precisely why it is novel.
A narrower fair-use victory looks considerably more plausible. A judge could conclude: AMA owns CPT, but it cannot use that ownership to stop this particular nonprofit from making legally mandated material freely readable by the public. The recent technical-standard cases provide a substantial road map for exactly such an outcome.
There could also be an intermediate ruling separating material. Perhaps codes, descriptors or guidelines actually incorporated into binding governmental requirements receive one treatment, while commentary, explanatory material, annotations, editorial organization or other value-added AMA content receives another. The joint-authorship claim could similarly make older portions of CPT public domain without destroying protection for all subsequently added material.
And the copyright-misuse count might become the vehicle for still another narrow result: the copyright remains valid, but AMA cannot enforce it until the court is satisfied that the effects of the old exclusive government arrangement have actually been purged.
In other words, the most consequential PRA win need not be “AMA loses copyright.”
It could simply be “AMA cannot stop this free public CPT.”
For the AMA's business model, that might be consequential enough.
There Are Non-Court Endgames Too
The litigation is taking place while CMS itself is asking whether the government should remain dependent upon this arrangement.
That creates several possible endgames that have little to do with a judge declaring the entire CPT system illegal.
AMA could respond politically by making basic CPT content freely searchable while continuing to charge commercial users for APIs, bulk data, integration, software products, enhanced commentary and other services. That would preserve a standardized national coding organization while substantially blunting PRA’s public-access argument.
CMS could also change the government's relationship to CPT without replacing every five-digit code overnight. The practical costs of abruptly replacing a coding system embedded in virtually every claim, payer, EHR, contract and billing system would be enormous. But CMS could demand different licensing terms, require free public access as a condition of continued federal adoption, or gradually develop an open governmental alternative.
Meanwhile, CMS can separately reform its reliance on the RUC even if CPT survives intact. One need not replace the language used to identify a colonoscopy in order to change who estimates the work, time and resources associated with the colonoscopy.
So the July RFI and the August lawsuit are not redundant. They are two independent pressure points on the same longstanding structure.
Cassidy: Yes, the Same Cassidy
And there is now a third pressure point: Congress.
The complaint prominently cites Sen. Bill Cassidy, M.D. (R-La.), chairman of the Senate HELP Committee, who began pressing the AMA over CPT licensing in 2025 and accused it of abusing a government-backed monopoly. Cassidy's committee has continued pursuing the issue directly with the AMA.
And yes—same duck.
There is one small chronology point worth keeping straight. The Cassidy X post appearing with the current Washington Post coverage is actually from July 15, before the PRA lawsuit. Cassidy wrote that AMA benefits from a government-backed CPT monopoly, that licensing fees raise costs, that he has been investigating it, and that the administration is right to scrutinize the arrangement.
So I would describe Cassidy's X post as strong support for the underlying challenge to the CPT arrangement, rather than technically as an endorsement of the August 13 lawsuit itself. Politically, however, the alignment could hardly be clearer.
And, Once Again, Dan Diamond Is There Very Early
There is one last bit of déjà vu.
When the administration's CPT/RUC RFI surfaced in mid-July, Dan Diamond at the Washington Post was on the story essentially immediately. As I noted at the time, the speed, detail and administration sourcing stood out, particularly because almost nobody else had picked up what was buried in an enormous CMS rule.
Now comes the PRA lawsuit.
Again, Diamond and the Washington Post were right at the starting line, publishing the August 13 story with an interview with PRA founder Cynthia Fisher and connecting it directly to the administration's CPT review and Cassidy's investigation. Trade publications followed quickly thereafter.
There is no need to speculate about sourcing to notice the pattern.
Mid-July: a surprisingly aggressive federal CPT/RUC review emerges; Diamond/WaPo has the major story immediately.
Mid-August: a surprisingly aggressive federal lawsuit against CPT ownership emerges; Diamond/WaPo again has the major story immediately.
At minimum, Washington's once-obscure CPT policy world has acquired a very visible national-media channel.
Bottom Line
For decades, CPT has occupied an unusual position that everyone in health care learned simply to accept. The AMA owns it. The government requires it. Everybody uses it. Everybody builds software around it. Many people pay to access it. And every year the AMA changes it.
The PRA lawsuit asks whether those propositions can continue to coexist.
The plaintiff has deliberately chosen an unusually sympathetic factual setting: a nonprofit wants to give the public free access to a coding system that federal and state law compel the public and the health care industry to use. Its complaint combines a broad constitutional/copyright argument, a much more pragmatic fair-use argument, and a copyright-misuse argument with the extraordinary advantage of having an earlier appellate decision saying that this very defendant once misused this very copyright.
AMA has serious defenses, particularly against the broad proposition that incorporation into law automatically destroys copyright. But the more limited fair-use claim arrives at a moment when recent appellate precedent has been moving decidedly in the direction of public access to incorporated technical standards.
And this is no longer occurring in isolation.
CMS is questioning CPT and the RUC. Cassidy is investigating CPT licensing. PRA is suing over CPT copyright. Recent appellate courts are expanding public access to incorporated private standards.
A month ago, the CMS RFI looked like an unusually provocative shot across the AMA's bow.
It now looks more like the opening shot.
