Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Pulmonary Rehabilitation

Policy #:10.04.01k

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.

Outpatient pulmonary rehabilitation is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has moderate to moderately severe respiratory impairment due to one of the following conditions:
    • Chronic pulmonary disease (e.g., chronic obstructive pulmonary disease (COPD), asthma, emphysema, bronchiectasis, cystic fibrosis, chronic bronchitis, interstitial lung disease)
    • Other conditions that may cause impaired pulmonary function (e.g., muscular dystrophy, Guillain-Barre syndrome, sarcoidosis)
  • The individual continues to be symptomatic (e.g., dyspnea, fatigue) despite optimal medical management (e.g., oxygen, bronchodilators)
  • The individual presents with reduced exercise tolerance, which affects performance of activities of daily living

In addition to the above conditions, outpatient pulmonary rehabilitation is considered medically necessary and, therefore, covered for either of the following:
  • Pre- and post-lung transplantation
  • Pre- and post-lung-volume-reduction surgery

Outpatient pulmonary rehabilitation is considered not medically necessary and, therefore, not covered when the above criteria are not met because the available published peer-reviewed literature does not support its use in the treatment of illness or injury.

EXPERIMENTAL/INVESTIGATIONAL

Home-based pulmonary rehabilitation 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.

NONCOVERED (BENEFIT CONTRACT EXCLUSION)

When an individual receiving pulmonary rehabilitation services has reached a point in their rehabilitation at which additional therapy is unlikely to yield an improvement in functional ability, ongoing therapy will be considered maintenance. Maintenance therapy is not covered by the Company because it is a benefit contract exclusion. Therefore, it is not eligible for reimbursement consideration.

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

Pulmonary rehabilitation programs should meet all of the following requirements:
  • The setting should have the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment (e.g., oxygen, cardiopulmonary resuscitation equipment, defibrillator).
  • A physician should be immediately available and accessible for medical consultations and emergencies at all times that the pulmonary rehabilitation services are being furnished.
  • The physician supervising the pulmonary rehabilitation program should have expertise in the management of individuals with respiratory pathophysiology and be involved substantially, in consultation with staff, in directing the progress of individuals in the pulmonary rehabilitation program.
  • The components of the pulmonary rehabilitation program must include all of the following components:
    • Professional provider--prescribed exercise. This physical activity includes techniques such as exercise conditioning, breathing retraining, and step and strengthening exercises. Some aerobic exercise must be included in each pulmonary rehabilitation session. Both low- and high-intensity exercise is recommended to produce clinical benefits, and a combination of endurance and strength training should be conducted at least twice per week.
    • Education or training. This should be closely and clearly related to the individual's care and treatment and tailored to the individual's needs, including information on respiratory problem management and, if appropriate, brief smoking cessation counseling. Any education or training must assist in achievement of individual goals towards independence in activities of daily living, adaptation to limitations, and improved quality of life (QoL).
    • Psychosocial assessment. This assessment means a written evaluation of an individual’s mental and emotional functioning as it relates to the individual’s rehabilitation or respiratory condition. It should include: (1) an assessment of the aspects of the individual’s family and home situation that affect the individual’s rehabilitation treatment, and (2) a psychological evaluation of the individual’s response to, and rate of progress under, the treatment plan. Periodic re-evaluations are necessary to ensure that the individual’s psychosocial needs are being met.
    • Outcomes assessment. These should include: (1) beginning and end evaluations based on patient-centered outcomes, which are conducted by the professional provider at the start and end of the program, and (2) objective clinical measures of the effectiveness of the pulmonary rehabilitation program for the individual patient, including exercise performance and self-reported measures of shortness of breath and behavior. The assessments should include clinical measurements such as the 6-minute walk, weight, exercise performance, self-reported dyspnea, behavioral measures (supplemental oxygen use, smoking status), and a quality-of-life assessment.
    • Individualized treatment plan describing the individual’s diagnosis and detailing how components are utilized for each individual. The plan must be established, reviewed, and signed by a professional provider every 30 days. The plan may initially be developed by the referring professional provider or the pulmonary rehabilitation professional provider. If the plan is developed by a referring professional provider who is not the pulmonary rehabilitation professional provider, the pulmonary rehabilitation professional provider must also review and sign the plan prior to initiation of the pulmonary rehabilitation program. It is expected that the supervising professional provider would have initial, direct contact with the individual prior to subsequent treatment by ancillary personnel, and also have at least one direct contact in each 30-day period. The plan must have written specificity regarding type, amount, frequency, and duration of pulmonary rehabilitation items and services furnished to the individual, and specify the appropriate mix of services for the individual's needs. The plan must also include measurable and expected outcomes and estimated timetables to achieve these outcomes.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, pulmonary rehabilitation is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary, as experimental/investigational, or as benefit contract exclusions are not eligible for coverage or reimbursement by the Company.

Medical necessity determination applies only if the pulmonary rehabilitation benefit exists and has not been exhausted, and no contract exclusions are applicable. For individuals enrolled in the Company's commercial products, individual benefits must be verified as limitations may apply.

BILLING GUIDELINES

When part of a comprehensive pulmonary rehabilitation program, providers should report the specific Healthcare Common Procedure Coding System (HCPCS) Level II code (S9473 and G0424) that describes pulmonary rehabilitation as a program.

The components of pulmonary rehabilitation, as part of a multidisciplinary treatment, may include services performed by a variety of professional therapy disciplines and should be reported using the most appropriate billing codes for the services performed.

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

Description

Pulmonary rehabilitation, as defined by the American Thoracic Society/European Respiratory Society (ATS/ERS) and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), is a "comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education and behavior change." Comprehensive pulmonary rehabilitation programs include:
  • Patient assessment: input from a physician, respiratory care practitioner, occupational therapist, physical therapist, nurse, psychologist, and other health care professionals
  • Exercise training: strengthening and conditioning, and may include stair climbing, inspiratory muscle training, treadmill walking, and unsupported arm exercise training
  • Patient education: breathing retraining, bronchial hygiene, medications, and proper nutrition
  • Psychosocial support: support system and dependency issues

Pulmonary rehabilitation programs have primarily been studied in, and utilized by, individuals with chronic obstructive pulmonary disease (COPD) and have been shown to significantly improve outcomes. In a meta-analysis of nine studies reporting on 432 individuals with recently exacerbated COPD, Puhan et al., (2011) compared outcomes in individuals undergoing pulmonary rehabilitation to those undergoing conventional therapy. The primary outcome of interest was subsequent hospital admissions post-intervention, while secondary outcomes included mortality, health-related quality of life and exercise capacity. In pooled analysis of the outcomes, the authors found that at 25 weeks post-intervention, individuals undergoing pulmonary rehabilitation experienced significantly fewer subsequent hospital admissions compared to those undergoing conventional therapies (odds ratio 0.22; 95% CI 0.08 to 0.58). Additionally, the study found that pulmonary rehabilitation significantly improved secondary outcomes of interest such as quality of life, fatigue, dyspnea, etc. The authors concluded that these results provide strong evidence that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions, mortality, and other outcomes in individuals with COPD who have recently suffered an exacerbation of their condition.

Individuals with chronic respiratory diseases other than COPD e.g., cystic fibrosis, asthma, bronchiectasis, and other chronic conditions have also been shown to benefit from structured pulmonary rehabilitation programs; however, these conditions have not been studied as extensively as COPD, largely because of their lower prevalence, and the published literature mainly consists of observational studies i.e., case series, case reports, etc. Nonetheless, the use of this intervention for these individuals is recommended by some professional societies. In a joint statement issued in 2013, the ATC/ERS stated that pulmonary rehabilitation may be valuable for conditions other than COPD in which respiratory symptoms are associated with reduced health-related quality of life or diminished functional capacity.

Pulmonary rehabilitation is also recommended for individuals awaiting lung-volume-reduction surgery and lung transplantation. In these individuals, the intervention should be offered pre-surgery for stabilization, improvement of activity tolerance, and instruction in techniques beneficial to post-surgery recovery. The demonstrated outcomes of pulmonary rehabilitation noted by the AACVPR include:
  • Reduced dyspnea and fatigue
  • Increased exercise performance
  • Enhanced performance of activities of daily living
  • Improved anxiety and depression symptoms

Pulmonary rehabilitation may be initiated during an inpatient stay and is typically offered in an outpatient setting. Although pulmonary rehabilitation may be available in the home setting, based on a review of available published literature, there is no published data addressing the impact of a comprehensive home-based pulmonary rehabilitation program on net health outcomes.
References


American Association of Cardiovascular and Pulmonary Rehabilitation. Pulmonary Rehabilitation Patient Resources. Available at: https://www.aacvpr.org/Resources/Resources-for-Patients/Pulmonary-Rehab-Patient-Resources. Accessed April 9, 2018.

American Thoracic Society (ATS) Pulmonary rehabilitation. [ATS Web site]. Available at: http://www.thoracic.org/members/assemblies/assemblies/pr/ Accessed April 9, 2018.

Beauchamp MK, Janaudis-Ferreira T, Goldstein RS et al. Optimal duration of pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease--a systematic review. Chron Respir Dis. 2011;8(2):129-40.

Beling J. Improved health-related quality of life after lung volume reduction surgery and pulmonary rehabilitation. Cardiopulm Phys Ther J. 2009;20(3):16-22.

Benzo R, Wigle D, Novotny P, et al. Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Lung Cancer. 2011;74(3):441-445.

Bolton CE, Bevan-Smith EF, Blakey JD et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax. 2013;68 Suppl 2:ii1-30.

Bradley A, Marshall A, Stonehewer L et al. Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery. Eur J Cardiothorac Surg. 2013;44(4):e266-71.

Carr SJ, Hill K, Brooks D, et al. Pulmonary rehabilitation after acute exacerbation of chronic obstructive pulmonary disease in patients who previously completed a pulmonary rehabilitation program. J Cardiopulm Rehabil Prev. 2009;29(5):318-324.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. 231: Pulmonary rehabilitation services furnished on or after January 1, 2010. [CMS Web site]. 02-02-18. Available at: https://www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed April 9, 2018.

Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 32: Billing requirements for special services. 140.4: Pulmonary rehabilitation services furnished on or after January 1, 2010. [CMS Web site]. 04/13/18. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c32.pdf. Accessed April 9, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 240.8: Pulmonary rehabilitation services. [CMS Web site] Original: 9/25/07. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=320&ncdver=1&bc=AgAAgAAAAAAA&. Accessed April 9, 2018.

Company Benefit Contracts.

COPD Working Group. Pulmonary rehabilitation for patients with chronic pulmonary disease (COPD): an evidence-based analysis. Ont Health Technol Assess Ser. 2012;12(6):1-75.

Edvardsen E, Skjonsberg OH, Holme I, et al. High-intensity training following lung cancer surgery: a randomised controlled trial. Thorax. 2015;70(3):244-250.

Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003;348(21):2059-2073.

Fuller LM, Button B, Tarrant B, et al. Longer versus shorter duration of supervised rehabilitation after lung transplantation: a randomized trial. Arch Phys Med Rehabil. 2017;98(2):220-226.e223.

Gaunaurd IA, Gomez-Marin OW, Ramos CF, et al. Physical activity and quality of life improvements of patients with idiopathic pulmonary fibrosis completing a pulmonary rehabilitation program. Respir Care. 2014;59(12):1872-1879.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Vancouver (WA): Global Initiative for Chronic Obstructive Lung Disease (GOLD); 2011.

Gottlieb V, Lyngso AM, Nybo B, et al. Pulmonary rehabilitation for moderate COPD (GOLD 2)--does it have an effect? COPD. 2011;8(5):380-386.

Guell MR, Cejudo P, Ortega F, et al. Benefits of long-term pulmonary rehabilitation maintenance program in patients with severe chronic obstructive pulmonary disease. three-year follow-up. Am J Respir Crit Care Med. 2017;195(5):622-629.

Hoffman M, Chaves G, Ribeiro-Samora GA, et al. Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review. BMJ Open. 2017;7(2):e013445.

Jackson RM, Gomez-Marin OW, Ramos CF, et al. Exercise limitation in IPF patients: a randomized trial of pulmonary rehabilitation. Lung. 2014;192(3):367-376.

Jacome CI, Marques AS. Pulmonary rehabilitation for mild COPD: a systematic review. Respir Care Respir Care. 2014;59(4):588-94.

Kozu R, Senjyu H, Jenkins SC, et al. Differences in response to pulmonary rehabilitation in idiopathic pulmonary fibrosis and chronic obstructive pulmonary diseases. Respiration. 2011;81(3):196-205.

Langer D, Burtin C, Schepers L, et al. Exercise training after lung transplantation improves participation in daily activity: a randomized controlled trial. Am J Transplant. 2012;12(6):1584-1592.

Lee AL, Hill CJ, McDonald CF, et al. Pulmonary rehabilitation in individuals with non-cystic fibrosis bronchiectasis: a systematic review. Arch Phys Med Rehabil. 2017;98(4):774-782 e771.

Liu X-D, Jin H-Z, Ng B-P, et al. Therapeutic effects of qigong in patients with COPD: a randomized controlled trial. Hong Kong J Occup Ther. 2012;22(1):38-46.

Liu XL, Tan JY, Wang T, et al. Effectiveness of home-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a meta-analysis of randomized controlled trials. Rehabil Nurs. 2014;39(1):36-59.

Maltais F, Bourbeau J, Shapiro S, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2008;149(12):869-878.

McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;2(2):CD003793.

Morano MT, Araujo AS, Nascimento FB et al. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2013;94(1):53-8.

Munro PE, Holland AE, Bailey M, et al. Pulmonary rehabilitation following lung transplantation. Transplant Proc. 2009;41(1):292-295.

Neves LF, Reis MH, Goncalves TR. Home or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Cad Saude Publica. 2016;32(6).

Ong HK, Lee AL, Hill CJ, et al. Effects of pulmonary rehabilitation in bronchiectasis: a retrospective study. Chronic Respir Dis. 2011;81(1):21-30.

Puhan MA, Gimeno-Santos E, Cates CJ, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;12:CD005305.

Puhan MA, Gimeno-Santos E, Scharplatz M, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;(10):CD005305.

Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and the European Respiratory Society. Ann Intern Med. 2011;155(3):179-191.

Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: Joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(5 Suppl):4S-42S.

Roman M, Larraz C, Gomez A, et al. Efficacy of pulmonary rehabilitation in patients with moderate chronic obstructive pulmonary disease: a randomized controlled trial. BMC Fam Pract. 2013;14:21.

Rugbjerg M, Iepsen UW, Jorgensen KJ, et al. Effectiveness of pulmonary rehabilitation in COPD with mild symptoms: a systematic review with meta-analyses. Int J Chron Obstruct Pulmon Dis. 2015;10:791-801.

Salhi B, Troosters T, Behaegel M, et al. Effects of pulmonary rehabilitation in patients with restrictive lung diseases. Chest. 2010;137(2):273-279.

Spruit MA, Singh SJ, Garvey C, et al. An official american thoracic society/european respiratory society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013; 188(8):e13-64.

van Wetering CR, Hoogendoorn M, Mol SJ, et al. Short- and long-term efficacy of a community-based COPD management program in less advanced COPD: a randomised controlled trial. Thorax. 2010;65(1):7-13.

Vieira D, Maltais F, Bourbeau J. Home-based pulmonary rehabilitation in chronic obstructive pulmonary disease patients. Curr Opin Pulm Med. 2010;16(2):134-143.

Wickerson L, Mathur S, Brooks D. Exercise training after lung transplantation: a systematic review. J Heart Lung Transplant. 2010;29(5):497-503.

Wilson AM, Browne P, Olive S, et al. The effects of maintenance schedules following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomised controlled trial. BMJ Open. 2015;5(3):e005921.





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)

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 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)

N/A


HCPCS Level II Code Number(s)



G0424 Pulmonary Rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day.

S9473 Pulmonary rehabilitation program, non-physician provider, per diem



Revenue Code Number(s)

0948 Other Therapeutic Services - Pulmonary Rehabilitation


Coding and Billing Requirements



Policy History

Revisions from 10.04.01k:
06/06/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulmonary Rehabilitation.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 04/23/2014
Version Issued Date: 04/23/2014
Version Reissued Date: 06/06/2018

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.