Medical Policy Bulletin

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Title:

Cardiac Rehabilitation

Policy #:

10.01.01g

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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.

Intent

The intent of this policy is to communicate the medical necessity criteria for cardiac rehabilitation.

Description

Cardiac rehabilitation programs are regulated exercise programs that effectively manage the physiological rehabilitation of individuals with cardiac conditions. Cardiac rehabilitation also 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. 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 generally last up to 36 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 physician's revision of the prescribed exercise program, or limited examination by a physician for the purpose of adjusting medication or other treatment regimens. The goal of cardiac rehabilitation is to return an individual to optimal health status in order to resume his/her former vocation or lifestyle. Cardiac rehabilitation is recommended for adult individuals with heart failure or stable angina pectoris and for individuals who are pre- or post-heart transplantation. Substantial evidence from both mortality and morbidity studies supports the benefit of a cardiac rehabilitation program. Cardiac rehabilitation has been shown to reduce morbidity and significantly improve the exercise performance of children with medical conditions and surgical repair of the heart (eg, congenital heart disease and following heart transplantation). The sustained effects of cardiac rehabilitation in children include improvements in exercise function and health status.

Policy

Cardiac rehabilitation is considered medically necessary and, therefore, covered for any of the following conditions or situations: 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 An ongoing maintenance program (ie, when rehabilitation no longer produces measurable progress or the individual no longer requires physician supervision for the rehabilitation program) is considered not medically necessary and, therefore, not covered. Educational services (eg, 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 (eg, aortic stenosis, heart or heart-lung transplantation, Tetralogy of Fallot, transposition of the great vessels). 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 health care professional'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

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 the medical policy are met. MEDICARE This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare. Cardiac rehabilitation is usually performed in the outpatient setting (eg, facility-based location, physician suite); however, initial treatment may start in the inpatient setting. Cardiac rehabilitation alone is not cause for admission to the hospital inpatient setting. For most individuals, cardiac rehabilitation can be completed in 36 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. Cardiac rehabilitation programs should meet all of the following requirements: A physician is available to perform medical duties at all times the facility is open. The facility has available all of the necessary cardiopulmonary emergency diagnostic and therapeutic life-saving equipment accepted by the medical community as medically necessary (eg, oxygen, cardiopulmonary resuscitation equipment). The program is conducted in an area set aside for the exclusive use of the program while it is in session. 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. The services of nonphysician personnel must be furnished under the direct supervision of a physician. Direct supervision means that a physician must be in the exercise program area and immediately available and accessible for an emergency at all times the exercise program is being conducted. Nonphysician personnel are employees of either the physician or the hospital conducting the program. Cardiac rehabilitation 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 nonphysician personnel in a cardiac rehabilitation facility are not eligible for direct reimbursement because reimbursement is provided only to the physician or hospital conducting the program. Cardiac rehabilitation is a separate service from physical and occupational therapy. Clinical practice and recent literature support cardiac rehabilitation in children. 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 children with congenital heart disease with an increase in stroke volume and/or oxygen extraction during exercise. With respect to heart transplantation in both children and adults, 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.

References

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, PA: Lippincott-Raven; 1998: 1337. 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. [ACC Web site]. 11/17/02. Available at: http://www.acc.org/qualityandscience/clinical/guidelines/stable/stable_clean.pdf. Accessed October 1, 2009. 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. Also available on the Circulation Web site at: http://circ.ahajournals.org/cgi/content/full/114/24/2710. Accessed October 1, 2009. Lavie CJ, Milani RV. Cardiac rehabilitation and preventive cardiology in the elderly. Cardiol Clin. 1999;17(1):233-242. 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. Medicare Learning Network (MLN). MLN Matters. MM4401: Cardiac rehabilitation programs. [Centers for Medicare & Medicaid Services (CMS) Web site]. 03/22/06. Available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4401.pdf. Accessed October 1, 2009. Moliterno DJ. Care after myocardial infarction. In: Rakel RE, ed. Conn's Current Therapy. 52nd ed. Philadelphia, PA: WB Saunders Co; 2000: 331-332. National Heart Lung and Blood Institute (NHLBI). Cardiac rehabilitation. [NHLBI Web site]. October 2007. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/rehab/rehab_whatis.html. Accessed October 1, 2009. 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. Also available on the Pediatrics Web site at: http://pediatrics.aappublications.org/cgi/content/full/116/6/1339. Accessed October 1, 2009. Rhodes J, Curran TJ, Camil L, et al. Sustained effects of cardiac rehabilitation in children with serious congenital heart disease. Pediatrics. 2006;118(3):e586-e593. Also available on the Pediatrics Web site at: http://pediatrics.aappublications.org/cgi/content/full/118/3/e586. Accessed October 1, 2009. Tegtbur U, Busse MW, Tewes U, Brinkmeier U. Ambulatory long-term rehabilitation of heart patients. Herz. 1999;24 Suppl 1:89-96. 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. Journal of the American College of Cardiology. 2007;50(14)1400-33.

Coding Table

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.

Code System	Code Number(s) and Narrative(s)
CPT	93797; 93798
ICD Procedure	N/A
ICD Diagnosis	THE FOLLOWING CODES ARE THE MEDICAL INDICATIONS FOR ALL LINES OF BUSINESS 394.0: Mitral stenosis 395.0: Rheumatic aortic stenosis 397.0: Diseases of tricuspid valve 397.1: Rheumatic diseases of pulmonary valve 398.91: Rheumatic heart failure (congestive) 402.01: Malignant hypertensive heart disease with heart failure 402.11: Benign hypertensive heart disease with heart failure 402.91: Unspecified hypertensive heart disease with heart failure 404.01: Hypertensive heart and kidney disease, malignant, with heart failure 404.03: Hypertensive heart and kidney disease, malignant, with heart failure and chronic kidney disease 404.11: Hypertensive heart and kidney disease, benign, with heart failure 404.13: Hypertensive heart and kidney disease, benign, with heart failure and chronic kidney disease 404.91: Hypertensive heart and kidney disease, unspecified, with heart failure 404.93: Hypertensive heart and kidney disease, unspecified, with heart failure and chronic kidney disease 410.00: Acute myocardial infarction of anterolateral wall, episode of care unspecified 410.01: Acute myocardial infarction of anterolateral wall, initial episode of care 410.02: Acute myocardial infarction of anterolateral wall, subsequent episode of care 410.10: Acute myocardial infarction of other anterior wall, episode of care unspecified 410.11: Acute myocardial infarction of other anterior wall, initial episode of care 410.12: Acute myocardial infarction of other anterior wall, subsequent episode of care 410.20: Acute myocardial infarction of inferolateral wall, episode of care unspecified 410.21 Acute myocardial infarction of inferolateral wall, initial episode of care 410.22: Acute myocardial infarction of inferolateral wall, subsequent episode of care 410.30: Acute myocardial infarction of inferoposterior wall, episode of care unspecified 410.31: Acute myocardial infarction of inferoposterior wall, initial episode of care 410.32: Acute myocardial infarction of inferoposterior wall, subsequent episode of care 410.40: Acute myocardial infarction of other inferior wall, episode of care unspecified 410.41: Acute myocardial infarction of other inferior wall, initial episode of care 410.42: Acute myocardial infarction of other inferior wall, subsequent episode of care 410.50: Acute myocardial infarction of other lateral wall, episode of care unspecified 410.51: Acute myocardial infarction of other lateral wall, initial episode of care 410.52: Acute myocardial infarction of other lateral wall, subsequent episode of care 410.60: Acute myocardial infarction, true posterior wall infarction, episode of care unspecified 410.61: Acute myocardial infarction, true posterior wall infarction, initial episode of care 410.62: Acute myocardial infarction, true posterior wall infarction, subsequent episode of care 410.70: Acute myocardial infarction, subendocardial infarction, episode of care unspecified 410.71: Acute myocardial infarction, subendocardial infarction, initial episode of care 410.72: Acute myocardial infarction, subendocardial infarction, subsequent episode of care 410.80: Acute myocardial infarction of other specified sites, episode of care unspecified 410.81: Acute myocardial infarction of other specified sites, initial episode of care 410.82: Acute myocardial infarction of other specified sites, subsequent episode of care 410.90: Acute myocardial infarction, unspecified site, episode of care unspecified 410.91: Acute myocardial infarction, unspecified site, initial episode of care 410.92: Acute myocardial infarction, unspecified site, subsequent episode of care 411.0: Postmyocardial infarction syndrome 411.1: Intermediate coronary syndrome 411.81: Acute coronary occlusion without myocardial infarction 411.89: Other acute and subacute form of ischemic heart disease 412: Old myocardial infarction 413.0: Angina decubitus 413.1: Prinzmetal angina 413.9: Other and unspecified angina pectoris 414.00: Coronary atherosclerosis of unspecified type of vessel, native or graft 414.01: Coronary atherosclerosis of native coronary artery 414.02: Coronary atherosclerosis of autologous vein bypass graft 414.03: Coronary atherosclerosis of nonautologous biological bypass graft 414.04: Coronary atherosclerosis of artery bypass graft 414.05: Coronary atherosclerosis of unspecified type of bypass graft 414.06: Coronary atherosclerosis of native coronary artery of transplanted heart 414.07: Coronary atherosclerosis, of bypass graft (artery) (vein) of transplanted heart 414.3: Coronary atherosclerosis due to lipid rich plaque 414.8: Other specified forms of chronic ischemic heart disease 414.9: Unspecified chronic ischemic heart disease 424.0: Mitral valve disorders 424.1: Aortic valve disorders 424.2: Tricuspid valve disorders, specified as nonrheumatic 424.3: Pulmonary valve disorders 424.90: Endocarditis, valve unspecified, unspecified cause 425.4: Other primary cardiomyopathies 428.0: Congestive heart failure, unspecified 428.1: Left heart failure 428.20: Unspecified systolic heart failure 428.22: Chronic systolic heart failure 428.30: Unspecified diastolic heart failure 428.32: Chronic diastolic heart failure 428.40: Unspecified combined systolic and diastolic heart failure 428.42: Chronic combined systolic and diastolic heart failure 428.9: Unspecified heart failure 429.4: Functional disturbances following cardiac surgery 429.79: Other certain sequelae of myocardial infarction, not elsewhere classified 429.89: Other ill-defined heart disease 429.9: Unspecified heart disease 440.0: Atherosclerosis of aorta 440.30: Atherosclerosis of unspecified bypass graft of extremities 440.31: Atherosclerosis of autologous vein bypass graft of extremities 440.32: Atherosclerosis of nonautologous biological bypass graft of extremities 440.9: Generalized and unspecified atherosclerosis 745.10: Complete transposition of great vessels 745.12: Corrected transposition of great vessels 745.2: Tetralogy of Fallot 746.85: Congenital coronary artery anomaly 746.9: Unspecified congenital anomaly of heart V42.1: Heart replaced by transplant V42.2: Heart valve replaced by transplant V43.21: Organ or tissue replaced by other means, heart assist device V43.22: Organ or tissue replaced by other means, fully implantable artificial heart V43.3: Heart valve replaced by other means V45.81: Postsurgical aortocoronary bypass status V45.82: Postsurgical percutaneous transluminal coronary angioplasty status
HCPCS Level II	S9472: Cardiac rehabilitation program, nonphysician provider, per diem 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 Codes	943: Cardiac rehabilitation

Version Effective Date: 01/01/2010