Commercial

Medical Policy

Title:

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

Policy #:

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 (CR) 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.
CR 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 CR program facility are not eligible for direct reimbursement because reimbursement is provided only to the professional provider or hospital conducting the program.

CR programs are services that are separate from physical and occupational therapy.

Clinical practice and recent literature support CR in pediatric individuals. In particular, a 12-week, semiweekly CR 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.

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.

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, CR 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, CR 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 (CR) program is a structured exercise and education program that effectively manages the physiological rehabilitation of individuals with cardiac conditions. CR 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. CR 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 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 CR 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.

CR 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 CR 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 CR 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 CR 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 ICR in 24 sites. These researchers concluded that ICR 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 were 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

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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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 10.01.01r:

04/15/2026	This policy has been reviewed and reissued to communicate the Company's continuing position on cardiac rehabilitation (CR) and intensive cardiac rehabilitation (ICR) programs.
02/19/2025	This policy has been reissued in accordance with the Company's annual review process.
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.
12/02/2020	This 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.

Version Effective Date:

3/11/2024

Version Issued Date: