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 | * The following article was archived on 03/21/2012.
Expanded Coverage of Intensive Cardiac Rehabilitation
Posted: 12/08/2010 | |
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| *For information on Cardiac Rehabilitation for other products offered by the Company, please refer to policy 10.01.01g, Cardiac Rehabilitation.
Effective immediately, the Company has extended coverage for intensive cardiac rehabilitation to individuals enrolled in the Company’s Medicare Advantage products. For individuals enrolled in Medicare Advantage products, intensive cardiac rehabilitation (ICR) is considered medically necessary and, therefore, covered when all of the following criteria are met:
- The individual has any of the following conditions:
- Compensated heart failure
- Myocardial infarction as a diagnosis documented within the preceding 12 months
- Stable angina pectoris in the presence of coronary artery disease (CAD)
- Post-coronary artery bypass surgery
- Post-heart transplantation or post-heart-lung transplantation
- Post-percutaneous transluminal coronary angioplasty or coronary stenting
- Post-heart valve repair or replacement
- The individual is participating in an ICR program that has been approved by the Centers for Medicare and Medicaid Services (CMS) (ie, Ornish Program for Reversing Heart Disease, Pritikin Program)
For individuals meeting the above criteria, ICR is limited to 72 one-hour sessions, up to 6 sessions per day, over a period for up to 18 weeks.
Once an individual begins ICR, he or she may not switch to cardiac rehabilitation (CR), and once an individual begins CR, he or she may not switch to ICR. Upon completion of an ICR or CR program, an individual must experience another indication in order to be eligible for coverage for more ICR or CR. If an individual experiences more than one indication simultaneously, he or she may participate in a single series of CR or ICR sessions.
Billing Requirements
Only providers and facilities that have been approved by Medicare to provide intensive cardiac rehabilitation are eligible to bill for this service.
Background
Cardiac rehabilitation programs are regulated exercise programs that effectively manage the physiologic rehabilitation of individuals with cardiac conditions. Cardiac rehabilitation (CR) also includes comprehensive services such as medical evaluation, individualized exercise programs, modification of cardiac risk factors, education about the prescribed regimen, and counseling to promote healthy lifestyles. Rehabilitation is an important management strategy for minimizing the adverse effects of cardiac illness and enhancing the psychosocial status of an individual. CR programs aim to reduce risk factors for reinfarction, sudden death, or other possible complications. These programs generally consist of up to 36 one-hour sessions.
Effective January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) established a benefit for intensive cardiac rehabilitation (ICR). ICR refers to a physician-supervised program that furnishes cardiac rehabilitation services more frequently and often in a more rigorous manner. All potential ICR programs must be evaluated and approved through the Centers for Medicare and Medicaid Services' (CMS) national coverage determination (NCD) process. For an ICR program to be approved, peer-reviewed published research must demonstrate that the ICR program improves individuals' cardiovascular disease as evidenced by decreases in five or more of the following measures:
- Low density lipoprotein levels
- Triglyceride levels
- Body mass index
- Systolic blood pressure
- Diastolic blood pressure
- The need for cholesterol, blood pressure, and diabetes medications
Additionally, an ICR program must demonstrate through peer-reviewed published research that it has accomplished one or more of the following for individuals:
- Positively affected the progression of heart disease
- Reduced the need for coronary bypass surgery
- Reduced the need for percutaneous coronary interventions
Effective August 12, 2010, CMS approved two ICR programs, the Ornish Program for Reversing Heart Disease and the Pritikin Program.
The Ornish Program for Reversing Heart Disease (also known as the Multisite Cardiac Lifestyle Intervention Program, the Multicenter Cardiac Lifestyle Intervention Program, and the Lifestyle Heart Trial Program) was initially described in the 1970s and incorporates comprehensive lifestyle modifications including exercise, a low-fat diet, smoking cessation, stress management training, and group support sessions. Over the years, the Ornish program has been refined but continues to focus on these specific risk factors.
The Pritikin Program was designed and adopted by Nathan Pritikin in 1955. The diet was modeled after the diet of the Tarahumara Indians in Mexico, which consisted of 10% fat, 13% protein, 75-80% carbohydrates, and provided 15-20 grams per day of crude fiber with only 75 mg/day of cholesterol. With his lifestyle modifications, Pritikin reduced his serum cholesterol from 280 mg/dL to 122 mg/dL within three years. Over the years, the Pritikin Program (also known as the Pritikin Longevity Program) evolved into a comprehensive program that is provided in a physician’s office and incorporates a specific diet (10%-15% of calories from fat, 15%-20% from protein, 65%-75% from complex carbohydrates), exercise, and counseling lasting 21 to 26 days.
CMS has determined that ICR should be limited to 72 one-hour sessions, up to 6 sessions per day, over a period for up to 18 weeks.
Contact
If you have any questions, please contact your Network Coordinator.
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