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Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
10.01.01r

Policy

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 individual's 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 CR exercise program are not eligible for separate reimbursement.

For pediatric individuals, the medical necessity for CR 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 CR (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.
Services provided by nonprofessional 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 professional provider 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 professional provider meets the requirements for direct supervision of physician office services, and for hospital outpatient services. “Direct supervision'' means the professional provider must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the professional provider must be present in the room when the procedure is performed.

CARDIAC REHABILITATION (CR) PROGRAM PROFESSIONAL PROVIDER REQUIREMENTS

Professional providers responsible for CR programs should oversee and/or supervise the CR program at a particular site. The professional provider, 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 1-hour sessions per episode. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual benefits must be verified as limitations may apply.​​

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 1-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 1-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 (BMI)
  • Systolic blood pressure
  • Diastolic blood pressure
  • Need for cholesterol, blood pressure, and diabetes medications
A nonexperimental study was conducted by Silberman et al., 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 BMI, 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

Aldana SG, Greenlaw R, Salberg A, et al. The effects of an intensive lifestyle modification program on carotid artery intima-media thickness: a randomized trial. Am J Health Promot. 2007;21(6):510-516.

Aldana SG, Whitmer WR, Greenlaw R, et al. Effect of intense lifestyle modification and cardiac rehabilitation on psychosocial cardiovascular disease risk factors and quality of life. Behav Modif. 2006;30(4):507-525.

Anderson L, Thompson DR, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016;1:CD001800.

Balady GJ, Ades PA, Bittner VA, et al. Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and Beyond: A Presidential Advisory from the American Heart Association. Circulation. 2011;124(25):2951-2960.

Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the councils on Cardiovascular Nursing, Epidemiology and Prevention, Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115(20):2675-2683.

Barnard RJ, Lattimore L, Holly RG, et al. Response of non-insulin-dependent diabetic patients to an intensive program of diet and exercise. Diabetes Care. 1982;5(4):370-374.

Barnard RJ, Massey MR, Cherny S, et al. Long-term use of a high-complex-carbohydrate, high-fiber, low-fat diet and exercise in the treatment of NIDDM patients. Diabetes Care. 1983;6(3):268-273.

Barnard RJ GP, Rosenberg JM, et al. Effects of an intensive exercise and nutrition program on patients with coronary artery disease: five year follow-up. J Cardiopulm Rehabil. 1983;3:183-190.

Casey A, Chang BH, Huddleston J, et al. A model for integrating a mind/body approach to cardiac rehabilitation: outcomes and correlators. J Cardiopulm Rehabil Prev. 2009;29(4):230-238.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 32: Billing requirements for special services. [CMS Web site]. 03/16/2023. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c32.pdf. Accessed September 12, 2023. 

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.10.1: 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 September 12, 2023. ​

​Clark AM, McAlister FA, Hartling L, et al. Randomized trials of secondary prevention programs in coronary artery disease a systematic review. December 2005. Prepared for Agency for Healthcare Research and Quality. Contract No. 290-02-0023. Available at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id31TA.pdf​. Accessed September 12, 2023. 

Corra U, Piepoli MF, Carre F, et al. Secondary prevention through cardiac rehabilitation: physical activity counselling 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):1967-1974.

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):605-606.

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):129-138.

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):1967-1976.

Flores AM, Zohman LR. Rehabilitation of the cardiac patient. In DeLisa JA, Gans BM, Bockenek WL, eds. Rehabilitation Medicine Principles and Practice. 3rd ed. Philadelphia: Lippincott-Raven; 1998:1337.

Fraker TD Jr, Fihn SD; 2002 Chronic Stable Angina Writing Committee. 2007 Chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 guidelines for the management of patients with chronic stable angina. J Am Coll Cardiol. 2007;50:2264.

Gibbons RJ, Abrams J, Chatterjee K, et al. American College of Cardiology (ACC)/American Heart Association (AHA) 2002 guideline update for the management of patients with chronic stable angina. Circulation. 2003;107(1):149-158.

Heart Failure Society of America. Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):475-539.

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

Hotta SS. Cardiac rehabilitation programs. Health Technol Assess Rep. 1991;3:1-10.

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. 

Kitzman DW, Brubaker PH, Morgan TM, et al. Exercise training in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial. Circ Heart Fail. 2010;3(6):659-667.
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.

Leon AS, Franklin BA, Costa F, et al. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease: An American Heart Association Scientific Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111(3):369-376.

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.

Long L, Mordi IR, Bridges C, et al. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev. 2019 Jan;1:CD003331.​

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

Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322.

National Heart Lung and Blood Institute (NHLBI). Cardiac rehabilitation. [NHLBI Web site]. Available at: http //www.nhlbi.nih.gov/health/dci/Diseases/rehab/rehab_whatis.html. Accessed September 12, 2023. 

Nilsson BB, Lunde P, Grogaard HK, et al. Long-term results of high-intensity exercise-based cardiac rehabilitation in revascularized patients for symptomatic coronary artery disease. Am J Cardiol. 2018;121(1):21-26.​

O'Connor CM, Whellan DJ, Lee KL, et al.; HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439-1450.

Oldridge N. Exercise-based cardiac rehabilitation in patients with coronary heart disease meta-analysis outcomes revisited. Future Cardiol. 2012;8(5):729-751.

Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet. 1990;336(8708):129-133.

Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280(23):2001-2007.

Pack QR, Goel K, Lahr BD, et al. Participation in cardiac rehabilitation and survival after coronary artery bypass graft surgery: a community-based study. Circulation. 2013;128(6):590-597.

Pandey A, Kitzman DW, Brubaker P, et al. Response to endurance exercise training in older adults with heart failure with preserved or reduced ejection fraction. J Am Geriatr Soc. 2017;65(8):1698-1704.
Pischke CR, Weidner G, Elliott-Eller M, Ornish D. Lifestyle changes and clinical profile in coronary heart disease patients with an ejection fraction of 40% in the Multicenter Lifestyle Demonstration Project. Eur J Heart Fail. 2007;9(9):928-934.

Qaseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157(10):735-743.

Razavi M, Fournier S, Shepard DS, et al. Effects of lifestyle modification programs on cardiac risk factors. PLoS One. 2014; 9(12):e114772.

Rhodes J, Curran TJ, Camil L, et al. Impact of cardiac rehabilitation on the exercise function of children with serious congenital heart disease. Pediatrics. 2005;116(6):1339-1345.

Rosenthal MB, Barnard RJ, Rose DP, et al. Effects of a high-complex-carbohydrate, low-fat, low-cholesterol diet on levels of serum lipids and estradiol. Am J Med. 1985;78(1):23-27.

Shepard DS, Stason WB, Strickler GK, et al. Summary: Evaluation of Lifestyle Modification and Cardiac Rehabilitation in Medicare Beneficiaries. Schneider Institutes for Health Policy, Heller School, MS 035, Brandeis University, Waltham, MA 02454-9110. [CMS Web site]. 04/30/2009. Available at: https://innovation.cms.gov/Medicare-Demonstrations/Medicare-Preventive-Services-Medicare-Lifestyle-Modification-Program-Demonstration.html. Accessed September 12, 2023. 

Silberman A, Banthia R, Estay IS, et al. The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. Am J Health Promot. 2010;24(4):260-266.

Stason WB, Shepard DS, Fournier S, et al. Effects of the Medicare Lifestyle Modification Program Demonstration on Cardiac Risk and Quality of Life. Appendix A.3 of the Evaluation of Lifestyle Modification and Cardiac Rehabilitation in Medicare Beneficiaries. Schneider Institutes for Health Policy Heller School, MS 035, Brandeis University Waltham, MA 02454-9110 USA. [CMS Web site]. 05/15/2009. Available at: https://innovation.cms.gov/Medicare-Demonstrations/Medicare-Preventive-Services-Medicare-Lifestyle-Modification-Program-Demonstration.html. Accessed September 12, 2023. ​​

Sullivan S, Samuel S. Effect of short-term Pritikin diet therapy on the metabolic syndrome. J Cardiometab Syndr. 2006;1(5):308-312.

Sumner J, Harrison A, Doherty P. The effectiveness of modern cardiac rehabilitation: A systematic review of recent observational studies in non-attenders versus attenders. PLoS One. 2017;12(5):e0177658.

Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease systematic and meta-analysis of randomized controlled trials. Am J Med. 2004;116(10):682-692.

Taylor RS, Sagar VA, Davies EJ, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014;4:CD003331.

Tegtbur U, Busse MW, Tewes U, Brinkmeier U. Ambulatory long-term rehabilitation of heart patients. Herz. 1999;24(Suppl1):89-96.

Thomas RJ, King M, Lui K, et al. 2007 Performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol. 2007;50(14):1400-1433.

Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation, Clinical Practice Guideline, No. 17. Clin Pract Guidel Quick Ref Guide Clin.1995;(17):1-23. Accessed September 12, 2023. 

West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT) multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart. 2012;98(8):637-644.

Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.

Zeng W, Stason WB, Fournier S, et al. Benefits and costs of intensive lifestyle modification programs for symptomatic coronary disease in Medicare beneficiaries. Am Heart J. 2013;165(5):785-792.

Coding

CPT Procedure Code Number(s)
93797, 93798
ICD - 10 Procedure Code Number(s)
N/A
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

Policy History

Revisions From 10.01.01r:
03/11/2024​This version of the policy will become effective 03/11/2024. 

The intent of this policy has not changed; however, the guidelines section has been revised to expand​ types of practitioners who may furnish direct supervision of cardiac rehabilitation programs​. ​

Revisions From 10.01.01q:
11/15/2023​This version of the policy will become effective 11/15/2023. 

The intent of this policy remains unchanged, however,​ the following ICD-10 code has been added to Attachment A of this policy:

Z95.818 Presence of other cardiac implants and grafts​

Revisions From 10.01.01p:
10/01/2023​This policy has been identified for the ICD-10 code update, effective 10/01/2023. 

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.


The following ICD-10 codes have been termed and removed from Attachment A of this policy:

I20.8 Other forms of angina pectoris

I24.8 Other forms of acute ischemic heart disease​

The following ICD-10 codes have been added to Attachment A of this policy:

I20.81 Angina pectoris with coronary microvascular dysfunction

I20.89 Other forms of angina pectoris

I21.B Myocardial infarction with coronary microvascular dysfunction

I24.81 Acute coronary microvascular dysfunction

I24.89 Other forms of acute ischemic heart disease

I25.85 Chronic coronary microvascular dysfunction


The following ICD-10 code narrative has been revised in Attachment A of this policy:

FROM:

I25.112 Atherosclerosic heart disease of native coronary artery with refractory angina pectoris

TO:

I25.112 Atherosclerotic heart disease of native coronary artery with refractory angina pertoris


Revisions From 10.01.01o:
10/01/2022​This policy has been identified for the ICD-10 code update, effective 10/01/2022. 

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.


The following ICD-10 code has been termed and removed from Attachment A of this policy:

I34.8 Other nonrheumatic mitral valve disorders


The following ICD-10 codes have been added to Attachment A of this policy:

 

I25.752  Atherosclerosis of native coronary artery of transplanted heart with refractory angina pectoris

I25.762  Atherosclerosis of bypass graft of coronary artery of transplanted heart with refractory angina pectoris

I25.792  Atherosclerosis of other coronary artery bypass graft(s) with refractory angina pectoris       

I34.81  Nonrheumatic mitral (valve) annulus calcification

I34.89  Other nonrheumatic mitral valve disorders


​Revisions From 10.01.01n:
​​06/29/2022
​This policy has been reviewed and reissued to communicate the Company’s continuing position on Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs.
​​10/06/2021

​This policy has been reissued in accordance with the Company's annual review process.​
12/02/2020This policy has been reviewed and reissued to communicate the Company’s continuing position on Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Programs.​
​09/25/2019
​This policy has been reissued in accordance with the Company's annual review process.
​02/15/2018
​The 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.
3/11/2024
3/11/2024
10.01.01
Medical Policy Bulletin
Commercial
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