Medicare Advantage

Medical Policy

Notification

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

Notification Issued Date:

Title:

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

Policy #:

MA10.002f

Policy

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) PROGRAM REQUIREMENTS

CR/ICR programs are considered medically necessary and, therefore, covered, when the following CR/ICR requirements are met:

The individual meets one of the following indications:

Acute myocardial infarction documented within the preceding 12 months
Post-coronary artery bypass surgery
Current stable angina pectoris
Post-heart valve repair or replacement
Post-percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
Post-heart or heart-lung transplant
Stable, chronic heart failure defined as left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms, despite being on optimal heart failure therapy for at least 6 weeks. (Note: stable is defined as no recent [≤ 6 weeks] or planned [≤ 6 months] major cardiovascular hospitalizations or procedures)

The CR or ICR program includes ALL of the following components:

Physician-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 physician each day CR/ICR 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/ICR, based on individual-centered outcomes, which must be measured by the physician; objective clinical measures of the effectiveness of the CR/ICR 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/ICR items/services furnished.
- The goals set for the individual under the plan. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.

The following programs have received approval from Original Medicare as a component of ICR:

The Ornish Program for Reversing Heart Disease
The Pritikin Program
The Benson-Henry Institute Cardiac Wellness Program

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) SESSION LIMITS

CR sessions are limited to a maximum of two 1-hour sessions per day up to 36 sessions furnished over a period of up to 36 weeks, with the option for an additional 36 sessions, over an extended period of time.

ICR sessions are limited to 72 one-hour sessions, up to six sessions per day, over a period of up to 18 weeks.

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) PROGRAM GUIDELINES

Once a individual begins CR, he or she may not switch to ICR, and once an individual begins ICR, he or she may not switch to CR.
Upon completion of a CR or ICR program, individuals must experience another indication in order to be eligible for coverage of more CR or ICR.
If an individual experiences more than one indication simultaneously, he or she may participate in a single series of CR or ICR sessions (i.e., an individual who had a myocardial infarction within 12 months and currently experiences stable angina is entitled to one series of CR sessions, up to 36 one-hour sessions with the option for an additional 36 sessions; or one series of ICR, up to 72 one-hour sessions over a period of up to 18 weeks).

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

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, cardiac rehabilitation and intensive cardiac rehabilitation programs are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

CARDIAC REHABILITATION AND INTENSIVE CARDIAC REHABILITATION

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

CARDIAC REHABILITATION (CR) AND INTENSIVE CARDIAC REHABILITATION (ICR) PROGRAM SETTING REQUIREMENTS
CR/ICR services should be furnished in a physician's office or a hospital outpatient setting (for ICR, the hospital outpatient setting should provide ICR using an approved ICR program). 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) AND INTENSIVE CARDIAC REHABILITATION (ICR) PROGRAM PROFESSIONAL PROVIDER REQUIREMENTS
Professional providers responsible for CR/ICR programs should oversee and/or supervise the CR/ICR 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/ICR program is offered

Description

CARDIAC REHABILITATION

Cardiac rehabilitation (CR) services mean a professional provider supervised program that furnishes physician prescribed exercise; cardiac risk-factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; outcomes assessment; and other items/services. CR programs aim to reduce risk factors for reinfarction, sudden death, or other possible complications, and are usually performed over 36 one-hour sessions.

INTENSIVE CARDIAC REHABILITATION

The intensive cardiac rehabilitation (ICR) program is a professional provider–supervised program that furnishes 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
Systolic blood pressure
Diastolic blood pressure
Need for cholesterol, blood pressure, and diabetes medications

MEDICARE-APPROVED PROGRAMS

A list of approved ICR programs and their approval dates are listed and maintained on the CMS Approved Facilities website at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/.

The following ICR programs have been approved by the Centers for Medicare & Medicaid Services (CMS) through the national coverage determination (NCD) process:

The Ornish Program for Reversing Heart Disease (also known as the Multisite Cardiac Lifestyle Intervention Program, the Multicenter Cardiac Lifestyle Intervention Program, and the Lifestyle Heart Trial Program) was initially described in the 1970s and incorporates comprehensive lifestyle modifications including exercise, a low-fat diet, smoking cessation, stress management training, and group support sessions. Over the years, the Ornish program has been refined but continues to focus on these specific risk factors.

The Pritikin Program was designed and adopted by Nathan Pritikin in 1955. The diet was modeled after the diet of the Tarahumara Indians in Mexico, which consisted of 10% fat, 13% protein, 75% to 80% carbohydrates, and provided 15 to 20 grams per day of crude fiber with only 75 mg/day of cholesterol. Over the years, the Pritikin Program (also known as the Pritikin Longevity Program) evolved into a comprehensive program that is provided in a professional provider’s office and incorporates a specific diet (10%-15% of calories from fat, 15%-20% from protein, 65%-75% from complex carbohydrates), exercise, and counseling lasting 21 to 26 days. An optional residential component is also available for participants.

The Benson-Henry Institute Cardiac Wellness Program was developed by Herbert Benson, MD, over 40 years ago. The Cardiac Wellness Program is a multicomponent intervention program that includes supervised exercise, behavioral interventions and counseling and is designed to reduce cardiovascular risk and improve health outcomes.

References

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 32: Billing requirements for special services. [CMS Web site]. 06/29/2023. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c32.pdf. Accessed December 19, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15 - Covered Medical and Other Health Services. [CMS Web site]. 10/12/2023. Available at: Medicare Benefit Policy Manual (cms.gov). Accessed December 19, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.1.1: Cardiac rehabilitation programs for chronic heart failure. [CMS website]. 02/18/2014. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=359&ncdVer=1. Accessed December 19, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31: Intensive cardiac rehabilitation (ICR) programs. [CMS website]. 08/12/2010. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=339&ncdver=1&DocID=20.31&bc=gAAAAAgAAAAAAA==&. Accessed December 19, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31.1: The Pritikin Program. [CMS website]. 08/12/2010. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=340&ncdver=1&bc=AAAAQAAAAAAAAA==&. Accessed December 19, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31.2: Ornish Program for Reversing Heart Disease. [CMS website]. 08/12/2010. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=341&ncdver=1&bc=AAAAQAAAAAAAAA==&. Accessed December 19, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.31.3: Intensive cardiac rehabilitation program - Benson-Henry Institute Cardiac Wellness Program. [CMS website]. 05/06/2014. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=362&ncdver=1&bc=AAAAQAAAAAAAAA==&. Accessed December 19, 2023.

Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS). CMS Ruling No.: [CMS-1784-F] Date: November 16, 2023. Available at: Federal Register :: Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program. Accessed December 21, 2023.

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)

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

S9472 Cardiac rehabilitation program, nonphysician provider, per diem

Revenue Code Number(s)

0943 Other Therapeutic Services--Cardiac Rehabilitation

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

3/11/2024

Version Issued Date: