Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs

Policy #:10.01.01n

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

CARDIAC REHABILITATION

MEDICALLY NECESSARY
Cardiac rehabilitation (CR) is considered medically necessary and, therefore, covered when BOTH of the following criteria are met:
  • The individual meets one of the following indications:
    • 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 or heart-lung transplantation
    • Post-percutaneous transluminal coronary angioplasty or coronary stenting
    • Post-heart valve repair or replacement
  • The CR program includes ALL of the following components:
    • Professional provider-prescribed exercise. This physical activity includes aerobic exercise combined with other types of exercise (i.e., strengthening, stretching) as determined to be appropriate for individuals by a professional provider each day CR items/services are furnished.
    • Cardiac risk-factor modification. This includes education, counseling, and behavioral intervention, tailored to individuals' needs.
    • Psychosocial assessment. This assessment means an evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation. It should include both:
      • An assessment of aspects of the individuals family and home situation that affect the individual’s rehabilitation treatment; and
      • A psychosocial evaluation of the individual’s response to, and rate of progress under, the treatment plan.
    • Outcomes assessment, which includes all of the following:
      • Assessments from the start and conclusion of CR, based on individual-centered outcomes, which must be measured by the professional provider; objective clinical measures of the effectiveness of the CR program for the individual, including exercise performance; and self-reported measures of exertion and behavior.
    • Individualized treatment plan. This plan should be written and tailored to each individual and include all of the following:
      • A description of the individual’s diagnosis.
      • The type, amount, frequency, and duration of the CR items/services furnished.
      • The goals set for the individual under the plan. The individualized treatment plan must be established, reviewed, and signed by a professional provider every 30 days.

Upon completion of the CR program, the member must experience another indication, as described above, in order to be eligible for an additional course of CR, if permitted under the individual's benefit contract.

Educational services (e.g., lectures, counseling) that may be provided as part of a cardiac rehabilitation exercise program are not eligible for separate reimbursement.

For pediatric individuals, the medical necessity for cardiac rehabilitation will be determined on an individual consideration basis for those with conditions that include but are not limited to congenital heart disease and cardiomyopathy, and for those individuals who have undergone cardiac surgery (e.g., aortic stenosis, heart or heart-lung transplantation, Tetralogy of Fallot, transposition of the great vessels).

NOT MEDICALLY NECESSARY
An ongoing maintenance program (i.e., when rehabilitation no longer produces measurable progress or the individual no longer requires professional provider supervision for the rehabilitation program) is considered not medically necessary and, therefore, not covered.

INTENSIVE CARDIAC REHABILITATION

EXPERIMENTAL/INVESTIGATIONAL
Intensive cardiac rehabilitation (e.g., Pritikin Program, Ornish Program) is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

CARDIAC REHABILITATION

Cardiac rehabilitation programs should meet all of the following requirements:
  • The facility has available all of the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment accepted by the medical community as medically necessary (e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator).
  • The program is staffed by a sufficient number of personnel who can conduct the program safely and effectively, and the personnel are trained in basic and advanced life-support techniques, as well as exercise therapy for coronary disease.
  • Cardiac rehabilitation programs shall be performed incident to professional provider’s services in outpatient hospitals, or outpatient settings such as clinics or offices.

Cardiac rehabilitation programs may not routinely include psychotherapy or psychological testing for all individuals enrolled in the program. Any psychotherapy or psychological services that are performed should be evaluated for coverage under the behavioral health/mental health benefit of a member's contract.

Services provided by non-professional providers in a cardiac rehabilitation program facility are not eligible for direct reimbursement because reimbursement is provided only to the professional provider or hospital conducting the program.

Cardiac rehabilitation programs are services that are separate from physical and occupational therapy.

Clinical practice and recent literature support cardiac rehabilitation in pediatric individuals. In particular, a 12-week, semiweekly cardiac rehabilitation program with home exercise has been shown to reduce morbidity and significantly improve the exercise performance of pediatric individuals with congenital heart disease with an increase in stroke volume and/or oxygen extraction during exercise.

With respect to heart transplantation in both pediatric and adult individuals, exercise training programs may result in increased exercise capacity (measured maximum oxygen uptake), decreased resting heart rate and blood pressure, improved endothelial function, and increased lean body mass.

CARDIAC REHABILITATION (CR) PROGRAM SETTING REQUIREMENTS

CR services should be furnished in a professional provider’s office or in a hospital outpatient setting. All settings should have a physician immediately available and accessible for medical consultations and emergencies at all times when items/services are being furnished under the program. This provision is satisfied if the physician meets the requirements for direct supervision of physician office services, and for hospital outpatient services. “Direct supervision'' means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

CARDIAC REHABILITATION (CR) PROGRAM PHYSICIAN REQUIREMENTS

Physicians responsible for CR programs should oversee and/or supervise the CR program at a particular site. The physician, in consultation with the staff, is involved in directing the progress of individuals in the program and must possess all of the following:
  • Expertise in the management of individuals with cardiac pathophysiology
  • Cardiopulmonary training in basic life support or advanced cardiac life support
  • Licensed to practice medicine in the state in which the CR program is offered

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, cardiac rehabilitation is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

For most individuals, cardiac rehabilitation can be completed in 36 one-hour sessions per episode. Medical necessity determination applies only if the benefit exists and has not been exhausted and no contract exclusions are applicable. Individual benefits must be verified as limitations may apply.

Subject to the terms and conditions of the applicable benefit contract, intensive cardiac rehabilitation is not eligible for payment under the medical benefits of the Company’s products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.
Description

CARDIAC REHABILITATION

A cardiac rehabilitation program is a structured exercise and education program that effectively manages the physiological rehabilitation of individuals with cardiac conditions. Cardiac rehabilitation includes comprehensive services such as medical evaluation, individualized exercise programs, modification of cardiac risk factors, education regarding the prescribed regimen, and counseling to promote healthy lifestyles. Cardiac rehabilitation is an important management strategy for minimizing the adverse effects of cardiac illness and enhancing the psychosocial status of an individual. Cardiac rehabilitation programs aim to reduce risk factors for reinfarction, sudden death, or other possible complications and are usually performed over 36 one-hour sessions.

Initially, a comprehensive evaluation may be performed to determine an appropriate exercise program for an individual. An electrocardiogram (ECG) stress test (treadmill or bicycle ergometer) may be performed to:
  • Evaluate chest pain (especially atypical chest pain)
  • Assist in the development of a prescribed exercise program if an individual has known cardiac disease
  • Evaluate the preoperative and postoperative status of an individual undergoing coronary artery bypass surgery

A routine cardiac rehabilitation visit may involve continuous ECG telemetric monitoring during exercise, ECG rhythm strip with interpretation and professional provider's revision of the prescribed exercise program, or limited examination by a professional provider for the purpose of adjusting medication or other treatment regimens.

Cardiac rehabilitation is indicated for conditions including but not limited to heart failure, myocardial infarction, and stable angina pectoris in adult individuals, and for adult individuals who are pre- and post-heart transplantation and post-cardiac surgery. Substantial evidence from mortality and morbidity studies supports the benefit of a cardiac rehabilitation program for adult individuals; such evidence also shows a reduction in morbidity and significant improvement in exercise performance of pediatric individuals with medical conditions, and in pediatric individuals following surgical repair of the heart (e.g., congenital heart disease and heart transplantation). The sustained effects of cardiac rehabilitation in pediatric individuals include improvements in exercise function and health status.

INTENSIVE CARDIAC REHABILITATION

Intensive cardiac rehabilitation (ICR) programs, such as the Ornish Program for Reversing Heart Disease, the Pritikin Program and the Benson-Henry Institute Cardiac Wellness Program, are physician-supervised programs that furnish cardiac rehabilitation services more frequently and in a more rigorous manner. The program is usually performed over 72 one-hour sessions (up to six sessions per day) over an 18-week period.

An ICR program must demonstrate its safety and efficacy through the following measures and outcomes.

It must accomplish one or more of the following for those participating in the program:
  • Positively affect the progression of heart disease
  • Reduce the need for coronary bypass surgery
  • Reduce the need for percutaneous coronary interventions

It must accomplish a statistically significant reduction in five or more of the following measures, as supported through published peer-reviewed research, from start to completion of the program:
  • Low-density lipoprotein blood levels
  • Triglycerides blood levels
  • Body mass index
  • Systolic blood pressure
  • Diastolic blood pressure
  • Need for cholesterol, blood pressure, and diabetes medications

A nonexperimental study was conducted by Silberman and colleagues, including Dean Ornish (2010), regarding the effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. These researchers concluded that intensive cardiac rehabilitation works when administered by a multidisciplinary staff. The design for this study was nonexperimental. Multiple subjective and objective health outcomes for 2974 participants were reported in this prospective time series that was conducted between 1998 and 2009. All staff that was involved in the administration of this intervention went through training sessions, and the program was standardized across all sites that were located in four states. However, all of the participants did not receive the same number of intervention sessions after the first 3 months due to risk stratification. Data for a number of outcomes, including those that should reduce over time through an intervention in order for it to qualify as an ICR program, were collected at baseline, 12 weeks, and 1 year. Although the authors reported a statistically significant improvement after 12 weeks in body mass index, low-density lipoprotein cholesterol, systolic and diastolic blood pressure, and total cholesterol, among other measures, additional significant improvement, for measures that pertain to ICR requirements, between 12 weeks and 1 year, occurred only in BMI and high-density lipoprotein cholesterol. Furthermore, there was significant recidivism in measures such as low-density lipoprotein cholesterol, systolic and diastolic blood pressure, and total cholesterol between 12 weeks and 1 year.

There are limitations associated with individual pieces of supporting evidence for ICR programs. For instance, the Lifestyle Heart Trial (Ornish Program), while having an appreciable follow-up and initial randomization and blinding, had a small sample size. For the Pritikin program, conclusions regarding its safety and efficacy have been reached through evaluations that consisted mainly of case-series and/or retrospective reporting. Limitations to the risk factor analyses of the Benson-Henry Institute Cardiac Wellness Program relate principally to the evaluation’s observational pre-post design with no control group. Seminal clinical studies that can fulfill the majority of relevant queries, which surround these programs as they pertain to the standards described for an ICR regimen, are lacking. Comprehensive, comparative, and prospective studies with appreciable follow-up and those that are conducted through the rigor required to satisfactorily minimize associated biases are warranted for programs that aim to establish themselves as ICR programs, through sustained improvements in required clinical parameters, outcomes, and events.
References

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Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.1.1: Cardiac rehabilitation programs for chronic heart failure. [CMS website]. 02/18/2014. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=359&ncdVer=1. Accessed January 12, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31: Intensive cardiac rehabilitation (ICR) programs. [CMS website]. 08/12/2010. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=339&ncdver=1&DocID=20.31&bc=gAAAAAgAAAAAAA%3D%3D&. Accessed January 12, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31.1: The Pritikin Program. [CMS website]. 08/12/2010. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=340&ncdver=1&bc=AAAAQAAAAAAAAA%3d%3d&. Accessed January 12, 2018.

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Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31.3: Intensive cardiac rehabilitation program - Benson-Henry Institute Cardiac Wellness Program. [CMS website]. 05/06/2014. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=362&ncdver=1&bc=AAAAQAAAAAAAAA%3d%3d&. Accessed January 12, 2018.

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Davies EJ, Moxham T, Rees K, et al. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev. 2010;(4):CD003331.

Doherty P, Lewin R. The RAMIT trial, a pragmatic RCT of cardiac rehabilitation versus usual care what does it tell us? Heart. 2012;98(8):605-6.

Dusek JA, Hibberd PL, Buczynski B, et al. Stress management versus lifestyle modification on systolic hypertension and medication elimination: a randomized trial. J Altern Complement Med. 2008;14(2):129-38.

European Association of Cardiovascular Prevention and Rehabilitation Committee for Science Guidelines; Corra U, Piepoli MF, Carre F et al. Secondary prevention through cardiac rehabilitation physical activity counseling and exercise training key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J. 2010;31(16):1967-76.

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Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;(7):CD001800.

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Joughin HM, Digenio AG, Daly L, Kgare E. Physiological benefits of a prolonged moderate-intensity endurance training programme in patients with coronary artery disease. S Afr Med J. 1999;89(5):545-550.

Kavey RE, Allada V, Daniels SR, et al. Cardiovascular risk reduction in high-risk pediatric patients a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research endorsed by the American Academy of Pediatrics. Circulation. 2006;114(24) 2710-2738.

Lavie CJ, Milani RV. Cardiac rehabilitation and preventive cardiology in the elderly. Cardiol Clin. 1999;17(1):233-242.

Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011;162(4):571-84 e2.

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Linxue L, Nohara R, Makita S, et al. Effect of long-term exercise training on regional myocardial perfusion changes in patients with coronary artery disease. Jpn Circ J. 1999;63(2):73-78.

McSherry R, Benison D, Shaw S, Davies A. The advantages of cardiac rehabilitation. Prof Nurse. 1999;14(9):612-615.

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Oldridge N. Exercise-based cardiac rehabilitation in patients with coronary heart disease meta-analysis outcomes revisited. Future Cardiol. 2012;8(5):729-51.

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Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

93797, 93798


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A


HCPCS Level II Code Number(s)

MEDICALLY NECESSARY


S9472 Cardiac rehabilitation program, nonphysician provider, per diem

EXPERIMENTAL/INVESTIGATIONAL

G0422 Intensive Cardiac Rehabilitation; with or without continuous ECG monitoring with exercise, per session

G0423 Intensive Cardiac Rehabilitation; with or without continuous ECG monitoring; without exercise, per session



Revenue Code Number(s)

0943 Other Therapeutic Services--Cardiac Rehabilitation

Coding and Billing Requirements


Cross References

Attachment A: Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
Description: ICD-10 Codes



Related Documents


Policy History

Revision from 10.01.01n
02/15/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs.
Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: 02/15/2018

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