Cardiac Rehabilitation in the Outpatient Setting

POLICY NUMBER

L.8.03.400

DESCRIPTION

Cardiac rehabilitation is the process by which people with cardiovascular disease are restored to their optimal functional status, including their physiological, psychological, social, vocational, and emotional status. Cardiac rehabilitation services include formal exercise sessions, risk factor education, and behavior modification counseling. Phase II cardiac rehabilitation is immediate outpatient therapy during the convalescent period following hospital discharge. Individualization of the program is achieved through a case management perspective with attention to patient and family needs.

POLICY

NOTE: This policy applies only to those benefit plans which specifically include cardiac rehabilitation as a benefit. This policy does not apply if cardiac rehabilitation is specifically excluded by the individual benefit plan. Also, most benefit plans limit cardiac rehabilitation to a maximum of 36 visits per calendar year regardless of the number of qualifying episodes per calendar year.

Prior approval is required for Fully Insured and most Self-Insured Groups.

Phase II Cardiac Rehabilitation

Phase II cardiac rehabilitation (immediate outpatient therapy during the convalescent period following hospital discharge) may be offered to patients with the following cardiovascular disease diagnoses (qualifying episodes) including:

• Myocardial infarction

• Coronary artery bypass graft

• Percutaneous transluminal coronary angioplasty, cardiac stent, atherectomy (DCA)

• Catheterization with diagnosis of coronary artery disease

• Peripheral vascular disease

• Arrhythmia

• Severely depressed left ventricular function (ejection fraction <30%)</li>

• Heart transplant

• Other diagnosis by specific physician referral

Contraindications for participation in Phase II cardiac rehabilitation include:

• Unstable angina

• Resting systolic blood pressure >200 mm Hg or resting diastolic blood pressure >110 mm Hg

• Significant drop (>=20 mm Hg) in resting systolic blood pressure from the patient’s average level that cannot be explained by medications

• Moderate to severe aortic stenosis

• Acute systemic illness or fever

• Uncontrolled atrial or ventricular arrhythmias

• Symptomatic congestive heart failure

• Third-degree heart block without pacemaker

• Active pericarditis or myocarditis

• Recent embolism

• Thrombophlebitis

• Uncontrolled diabetes

• Orthopedic problems that would prohibit exercise

• Other by specific physician instruction

Minimal Guidelines

Minimal guidelines for risk stratification are as follows:

Low Risk

• No significant left ventricular dysfunction (i.e., ejection fraction >=50%)

• No resting or exercise-induced myocardial ischemia manifested as angina and/or ST-segment displacement

• No resting or exercise-induced complex arrhythmias

• Uncomplicated myocardial infarction, coronary artery bypass surgery, angioplasty, or arthrectomy

• Functional capacity >=6 METs (Metabolic Equivalents) on graded exercise test 3 or more weeks after clinical event

Moderate Risk

• Mild to moderately depressed left ventricular function (ejection fraction 31%-49%)

• Fuctional capacity <5-6 METs (Metabolic Equivalents) on graded exercise test 3 or more weeks after clinical event

• Failure to comply with exercise intensity prescription

• Exercise-induced myocardial ischemia (1-2 mm ST-segment depression) or reversible ischemic defects (echocardiographic or nuclear radiography)

High Risk

• Severely depressed left ventricular function (ejection fraction <=30%)

• Complex ventricular arrhythmias at rest or appearing or increasing with exercise

• Decrease in systolic blood pressure of >15 mm Hg during exercise or failure to rise with increasing exercise workloads

• Survivor of sudden cardiac death

• Myocardial infarction complicated by congestive heart failure, cardiogenic shock, and/or complex ventricular arrhythmias

• Severe coronary artery disease and marked exercise-induced myocardial ischemia (>2mm ST-segment depression)

ECG Monitoring

Phase II cardiac rehabilitation may include continuous or intermittent ECG monitoring based on the patient’s risk level. The type and frequency of ECG monitoring should be determined on a patient-by-patient basis. Minimum guidelines to follow are:

• Use-intensive monitoring (e.g., continuous or more frequent intermittent ECG monitoring). A staff decision to use intermittent monitoring may be acceptable if the patient is clinically stable and exercise prescription is appropriately conservative.

• When clinically appropriate (i.e., no abnormal response to exercise or adverse signs or symptoms) progress to less intensive monitoring.

• Teach self-monitoring as a primary method of ensuring safety. Encourage frequent self-monitoring with appropriate checks by staff during the first 2 to 4 weeks.

• Use more intensive ECG monitoring when clinically warranted (i.e., abnormal response to exercise or adverse signs or symptoms).

• Evaluate patient’s exercise response and monitoring needs routinely, although not necessarily with a graded exercise test.

Initiation of Service

Formal cardiac rehabilitation service should be initiated within 3 months after discharge from the hospital.

Frequency and Duration of Service

Patient education and risk factor modification are considered part of the formal cardiac rehabilitation service.

Patients who are determined appropriate for cardiac rehabilitation based on recommendation by the referring physician and on patient selection criteria as outlined above are eligible for formal cardiac rehabilitation services.

The number of visits covered is based on patient severity as follows:

Three factors determine the appropriateness of discontinuing the cardiac rehabilitation program. These include:

• Evidence that the patient is clinically stable

• Achievement of the goals set at program entry

• Determination that the patient has received optimal or near-optimal benefits

The final decision as to risk determination shall be the joint responsibility of the referring physician and the director of the cardiac rehabilitation program.

Place of Service

Formal cardiac rehabilitation services must be conducted at a facility meeting the following criteria:

The cardiac rehabilitation program holds a current certification from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) and is listed in the AACVPR Program Directory online at https://www.aacvpr.org/Program-Directory. All AACVPR certified programs are listed in the online directory. The program does not have to be in the State of Mississippi, as long as it is certified by the AACVPR.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

1. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and 

2. appropriate with regard to standards of good medical practice; and 

3. not solely for the convenience of the Member, his or her Provider; and 

4. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

2/1999: Approved by the Medical Policy Advisory Committee (MPAC)

9/19/2000: Revisions to "Place of Service; "may" changed to "must" and the programs certified by AACVPR for Cardiac and Pulmonary Rehabilitation added

7/10/2001: Certified hospitals as of 5-31-2001 table added to "Place of Service", word "Pulmonary" deleted. This policy is specific to Cardiac Rehabilitation only.

8/2001: Reviewed by MPAC

9/20/2001: Natchez Regional Medical Center added to the Mississippi AACVPR certified program list

12/11/2001: Covered ICD-9 Procedure codes, ICD-9 Diagnosis codes, and Non-Covered ICD-9 Diagnosis codes added to the "Code Reference" section.

1/9/2002: Clay County Medical Center, North Mississippi Health Services and Oktibbeha County Hospital added to AACVPR certified program list

4/18/2002: Type of Service and Place of Service deleted.

5/14/2002: AACVPR table hyperlink added

5/29/2002: Code Reference section updated, ICD-9 procedure codes 36.11-36.17, 36.01-36.09 and 37.5 deleted

7/17/2002: Appeals statement deleted. Case Management reference deleted (depends on individual contract). Policy Guidelines statement added.

10/11/2002: ICD-9 Procedure code 89.44 deleted, HCPCS S9445 deleted

2/14/2003: AACVPR table updated, AACVPR hyperlink and separate AACVPR file deleted

6/12/2003: FEP Policy Exception deleted for Case Management and prior authorization, Case Management approval requirement added for underwritten and most self funded groups

6/18/2003: Magnolia Regional Health Center Cardiac Rehabilitation Program added to AACVPR certified program list

8/26/2003: Delta Regional Medical Center Cardiac Rehabilitation Program added to AACVPR certified program list

9/8/2003: Jackson Rehab and Wellness Center and Baptist Memorial Hospital DeSoto Cardiac Rehabilitation Programs added to AACVPR certified program list

9/18/2003: Hancock Medical Center Cardiac Rehabilitation Program added to AACVPR certified program list

10/10/2003: University of Mississippi Medical Center Cardiac Rehabilitation Center added to AACVPR certified program list

3/26/2004: Central Mississippi Medical Center, Garden Park Medical Center and Baptist Memorial Hospital at Oxford Cardiac Rehabilitation programs added to AACVPR certified program list

9/9/2004: Code Reference section updated, CPT code 93015, 93016 deleted covered codes, ICD-9 procedure code 93.36 added covered codes, ICD-9 diagnosis code range 410.00-410.92, 414.00-414.9, 427.0-427.9, 443.0-443.9 listed separately, ICD-9 diagnosis codes 426.10, 426.11, 426.12, 426.13, 426.2, 426.3, 426.4, 426.50, 426.51, 426.52, 426.53, 426.54, 426.6, 426.7, 426.81, 426.89, 426.9, 440.1, 440.20, 440.21, 440.22, 440.23, 440.24, 440.29, 440.30, 440.31, 440.32, 440.9, 441.00, 441.01, 441.02, 441.03, 441.1, 441.2, 441.3, 441.4, 441.5, 441.6, 441.7, 441.9, 442.0, 442.1, 442.2, 442.3, 442.81, 442.82, 442.83, 442.84, 442.89, 442.9, 459.81, 671.30, 671.31, 671.32, 671.33, 671.34, 671.40, 671.41, 671.42, 671.43, 671.44, V45.81, V45.82 added covered codes, rev code 943 deleted, non-covered table and codes 250.00-250.93, 411.1, 420.90, 420.91, 420.99, 422.90, 422.91, 422.92, 422.99, 424.1, 426.0, 428.0, 433.00-433.91, 434.1, 451.0-451.9, 780.6 deleted

10/5/2004: Singing River Hospital System/Ocean Springs Hospital Cardiac Rehabilitation added AACVPR certified program list

7/18/2005: AACVPR table updated, Southwest Mississippi Regional Medical Center Cardiac Rehabilitation added to AACVPR certified program list

9/15/2005: AACVPR table updated, Greenwood Leflore Hospital Cardiac Rehabilitation Department added to AACVPR certified program list

6/14/2006: AACVPR table updated, River Region Health System Cardiac Rehabilitation added to AACVPR certified program list

09/13/2006: Coding updated. ICD9 2006 revisions added to policy.

9/20/2007: Code reference section updated. ICD-9 2007 revisions added policy

9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied

3/12/2010: Code reference section updated. New HCPCS codes G0422 and G0423 added to covered table.

06/04/2010: Memorial Hospital at Gulfport Cardiac Rehabilitation Program added to AACVPR certified program list.

12/30/2010: Added "in the Outpatient Setting" to the policy title.

08/11/2011: Policy reviewed; no changes.

05/07/2013: Removed ICD-9 procedure code 93.36 from the Code Reference section.

08/26/2015: Medical policy revised to add ICD-10 codes. Removed deleted ICD-9 diagnosis codes 671.32, 671.34, 671.41, and 671.43 from the Code Reference section.

09/29/2015: Policy statement updated to replace the provider table with the link to the Online AACVPR Program Directory in the Place of Service section. All AACVPR certified programs are listed in the online directory.

05/27/2016: Policy number L.8.03.400 added.

11/17/2020: Added Policy Exceptions for Ergon, Inc. to state that cardiac rehabilitation is covered effective 07/01/2020. Services must be prior approved and rendered by a Network Provider. AACVPR accreditation is not required.

02/26/2021: AACVRP program directory link updated in the policy section.

08/22/2023: Policy reviewed; no changes.

09/29/2023: Code Reference section updated to add new ICD-10 diagnosis codes I25.85, I47.10, I47.11, and I47.19, effective 10/01/2023.

06/07/2024: Policy exceptions updated to delete Ergon, Inc. information. Added Medical Necessary definition to the Policy Guidelines. Minor wording changes in Policy section. No change to coverage criteria.

08/29/2024: Policy reviewed; no changes.

SOURCE(S)

1. A search of the literature was completed through the MEDLINE database for the period of January 1990 through October 1996. The search strategy focused on references containing the following Medical Subject Heading: Cardiac Rehabilitation.

2. American Association of Cardiovascular and Pulmonary Rehabilitation

3. Blue Cross Blue Shield Association policy # 8.03.08 

4. Cardiac Rehabilitation, Clinical Practice Guideline, Number 17, U.S. Department of Health & Human Services, October 1995.

5. Hayes Medical Technology Directory

6. HCFA, Coverage Issues Manual, section 35-25 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.