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Cardiac Rehabilitation Programs, Phase II Outpatient

Section: Visits
Effective Date: October 01, 2019
Revised Date: September 26, 2019
Last Reviewed: September 26, 2019

Description

Cardiac rehabilitation program, phase II refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of patients with heart disease and prevent future cardiac events. 

Criteria

Cardiac rehabilitation programs, Phase II Outpatient may be considered medically necessary when individually prescribed by a physician and the following criteria are met: 

  • Initiated within 12 months of ANY of the following: 
    • Acute myocardial infarction (MI) (heart attack); or
    • Coronary artery bypass graft (CABG) surgery); or
    • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
    • Heart valve surgery; or
    • Heart or heart-lung transplantation; or
    • Current stable angina pectoris; or
    • Compensated heart failure; or
    • Coronary artery disease (CAD) associated with chronic; stable angina pectoris that has failed to respond adequately to pharmacotherapy and is interfering with the ability to perform age-related activities of daily living and/or impairing functional abilities; and
  • The individual does not have an absolute contraindication to cardiac rehabilitation (examples include: unstable angina, overt cardiac failure, dangerous arrhythmias, dissecting aneurysm, myocarditis, acute pericarditis, severe obstruction of the left ventricular outflow tract, severe hypertension, exertional hypotension or syncope, uncontrolled diabetes mellitus, severe orthopedic limitations, and recent systemic or pulmonary embolus). 

The following are considered not medically necessary: 

  • Phase III cardiac rehabilitation programs, or self-directed, self-controlled or monitored exercise programs; 
  • Phase IV cardiac rehabilitation programs or maintenance therapy that may be safely carried out without medical supervision; 
  • Cardiac rehabilitation when used in a preventive or prophylactic way, such as for angina, hypertension, or diabetes. 

Following the initial evaluation, services provided in conjunction with a phase II outpatient cardiac rehab program may be considered medically necessary for up to 36 sessions, three (3) sessions per week, for a 12-week period. The need for supervised exercise sessions can be determined by the patient's risk stratification as follows: 

  • Low Risk: six (6)-18 exercise sessions 
  • Moderate Risk: 12-24 exercise sessions 
  • High Risk: 18-36 exercise sessions 

A routine cardiac rehabilitation session usually consists of an exercise training session lasting 20-60 minutes and at least ONE of the following services: 

  • Continuous ECG/EKG monitoring during exercise; or
  • EKG rhythm strip with interpretation and physician's revision of the exercise program; and/or
  • Limited physician follow-up to adjust medication or other treatment(s) related to the program. 

Cardiac rehabilitation exercise programs beyond the initial 12-week/36 session will require individual medical review. If documentation substantiates that additional sessions are medically necessary to reach a realistic and achievable increase in work capacity, the number of services may be extended, but not exceed a maximum of 24 weeks or 72 sessions. 

Maintenance exercise programs undertaken by the participant after formal freestanding clinic or facility based programs are completed, are not covered. 

Generally, psychotherapy and psychological testing are not considered medically necessary for all cardiac rehabilitation participants. However, if a participant has been diagnosed with a mental, psychoneurotic or personality disorder, psychotherapy performed by a psychiatrist or a psychologist may be considered medically necessary. In addition, psychological diagnostic testing of a cardiac rehabilitation participant who exhibits symptoms of mental illness or mental problems (e.g., anxiety disorder associated with the cardiac disease) may be considered medically necessary. 

Physical and/or occupational therapies are considered not medically necessary in conjunction with cardiac rehabilitation services unless performed for an unrelated diagnosis (e.g., a participant who is recuperating from an acute phase of heart disease may have also had a stroke which could require physical and/or occupational therapies). 

Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered experimental/investigational and therefore, non-covered. Scientific evidence does not support the need for repeat cardiac rehabilitation in the absence of cardiac events. 

Educational services (e.g., lectures, counseling) that may be provided as part of a cardiac rehabilitation exercise program are not eligible for separate reimbursement. 

Phase II cardiac rehabilitation services that do not meet the medical necessity criteria and frequency guidelines outlined on this policy will be denied as not medically necessary.

Procedure Codes

93797  93798  G0422  G0423

Risk stratification based on the American Association of Cardiovascular and Pulmonary Rehabilitation

(AACVPR)

Cardiac rehabilitation services are contraindicated in patients with the following conditions:

  • A recent significant change in the resting ECG suggesting significant ischemia, recent MI (within 2 days), or other acute cardiac event;
  • Severe residual angina;
  • Uncompensated heart failure;
  • Uncontrolled arrhythmias;
  • Symptomatic severe aortic stenosis;
  • Severe ischemia, LV dysfunction, or arrhythmia during exercise testing;
  • Poorly controlled hypertension;
  • Acute pulmonary embolism or pulmonary infarction;
  • Acute myocarditis or pericarditis;
  • Suspected or known dissecting aneurysm;
  • Acute systemic infection, accompanied by fever, body aches, or swollen lymph glands;
  • Hypertensive or any hypotensive systolic blood pressure response to

Relative contraindications to exercise include:

  • Left main coronary stenosis;
  • Moderate stenotic valvular heart disease;
  • Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia);
  • Severe arterial hypertension (i.e., systolic BP lf greater than 200mm Hg and/or diastolic BP of greater than 110 mm Hg) at rest;
  • Tachydysrhythmia or bradydysrhythmia;
  • Hypertrophic cardiomyopathy and other forms of outflow tract obstruction;
  • Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise;
  • High-degree atrioventricular block;
  • Ventricular aneurysm;
  • Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or myxedema);
  • Chronic infectious disease (e.g., mononucleosis, hepatitis, AIDS);
  • Mental or physical impairment leading to inability to exercise

The participant’s risk for another coronary event determines the status of the individual as a high moderate-, or low-risk. Use of early (pre-discharge) exercise testing, with or without radionuclide studies, provides the ability to determine the probability of a proximate ischemic event. Risk stratification testing benefits all participants regardless of their level of risk.

Initially, a comprehensive evaluation may be performed to evaluate the participant and determine an appropriate exercise program.

In addition to typical program duration, an endpoint for cardiac rehabilitation services may also be determined using the participant’s work capacity as measured by metabolic equivalents of task (MET). A MET is the measurement of the work required from the cardiovascular and pulmonary systems by a given activity. One MET equals approximately 3.5 ml of oxygen consumption per kilogram of body weight per minute.

Depending on variables such as age, sex, cardiac history, the existence of other complicating medical conditions, etc., work capacity usually levels out at a maximal level of five (5) to eight (8) METs for most cardiac rehabilitation participants. Reasonable endpoint criteria for medically supervised cardiac rehabilitation programs can include the ability of the participant to exercise at a level of eight (8) or more

METs without cardiac symptoms and the acquisition of the skills necessary for the self-monitoring of an unsupervised exercise program.

Since many participants with cardiac disease will not be capable of achieving this level of work capacity, the absence of improvement in capacity after three (3) serial exercise tests can be used as an alternative endpoint indicator.

Once a participant’s maximal work capacity has leveled out, ongoing exercise is considered maintenance. Additional cardiac rehabilitation services are eligible based on the clinical criteria defined in this policy when the individual has a repeat occurrence of the covered conditions, e.g., another cardiovascular surgery, a new MI, etc.

Diagnosis Codes

A18.84  I21.A1  I25.700  I25.738  I25.810  I46.2  I50.42 
I21.01  I21.A9  I25.701  I25.739  I25.811  I46.8  I50.43 
I21.02  I22.0  I25.708  I25.750  I25.812  I46.9  I50.9 
I20.1  I22.1  I25.709  I25.751  I42.0  I50.1  Z48.21 
I20.8  I22.2  I25.710  I25.758  I42.1  I50.20  Z48.280 
I20.9  I22.8  I25.711  I25.759  I42.2  I50.21  Z94.1 
I21.09  I22.9  I25.718  I25.760  I42.3  I50.22  Z94.3 
I21.11  I25.10  I25.719  I25.761  I42.4  I50.23  Z95.1 
I21.19  I25.110  I25.720  I25.768  I42.5  I50.30  Z95.2 
I21.21  I25.111  I25.721  I25.769  I42.6  I50.31  Z95.3 
I21.29  I25.118  I25.728  I25.790  I42.7  I50.32  Z95.4 
I21.3  I25.119  I25.729  I25.791  I42.8  I50.33  Z95.5 
I21.4  I25.2  I25.730  I25.798  I42.9  I50.40  Z98.61 
I21.9  I25.3  I25.731  I25.799  I43  I50.41  Z98.890

Professional Statements and Societal Positions Guidelines

The American College of Cardiology Foundation and the American Heart Association, 2013

In 2013, the American College of Cardiology Foundation and the American Heart Association published updated guidelines on the management of heart failure. These guidelines include the following Class IIA recommendation related to cardiac rehabilitation (Level of Evidence: B): Cardiac rehabilitation can be useful in clinically stable patients with heart failure to improve functional capacity, exercise duration, HRQOL (health-related quality of life), and mortality. 

The American College of Physicians, American College of Cardiology Foundation, American Heart Association/American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association and Society of Thoracic Surgeons, 2012

In 2012, the American College of Physicians, American College of Cardiology Foundation, American Heart Association/American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association and Society of Thoracic Surgeons published a joint guideline on management of stable ischemic heart disease. The guideline included the following statement on cardiac rehabilitation: Medically supervised exercise programs, i.e., cardiac rehabilitation and physician-directed home-based programs, are recommended for at-risk patients at first diagnosis of stable ischemic heart disease.