Pulmonary Rehabilitation

Policy ID: G-17-035

Section: Therapy

Effective Date: January 01, 2020

Revised Date: October 01, 2023

Revision Effective Date: October 01, 2023

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

Description

Pulmonary rehabilitation (PR) is a multidisciplinary approach to reducing symptoms and improving quality of life (QOL) in individuals with compromised lung function. Outpatient PR programs generally include a individual assessment followed by therapeutic interventions including exercise training, education, and behavior change.

Comprehensive outpatient PR programs may include: team assessment, individual training, psychosocial intervention, exercise training, and follow-up. Individuals should have the ability to perform the exercise training and have a high level of motivation to participate in and complete the program.

Individuals for PR should be medically stable and not limited by another serious or unstable medical condition. Contraindications to PR include but are not limited to:

Severe psychiatric disturbance (i.e., dementia, organic brain syndrome); or
Significant or unstable medical conditions (i.e., heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, or disabling stroke); or
Currently smoking.

The focus of therapy is to educate the individual and establish a program of adaptive changes to a chronic medical illness. The optimal outcome is achieved when the individual continues these adaptive changes on an independent basis after discharge from the program.

Criteria

Pulmonary Rehabilitation is a covered service for post COVID-19.

A single course of PR in the outpatient ambulatory care setting may be considered medically necessary for ANY of the following indications:

Treatment of chronic pulmonary disease for individuals with moderate to severe disease (see Table ) who are experiencing disabling symptoms and significantly diminished QOL despite optimal medical management; or
Preoperative conditioning component for those considered appropriate candidates for lung volume reduction surgery or for lung transplantation; or
Following lung transplantation.

Outpatient PR not meeting the criteria as indicated in this policy is considered not medically necessary.

Table

Classification of Severity of Airflow Limitation in COPD a, b

GOLD 1

Mild

FEV1 greater than or equal to 80% predicted

GOLD 2

Moderate

50% less than or equal to FEV1 less than 80% predicted

GOLD 3

Severe

30% less than or equal to FEV1 less than 50% predicted

GOLD 4

Very Severe

FEV1 less than 30% predicted

a Based on post-bronchodilator FEV1

b In individuals with FEV1/FVC less than 0.70

Procedure Codes

94625

94626

94640

94664

94667

94668

94760

94761

97001

97002

97110

97116

97150

97161

97162

97163

97164

97530

97750

99205

99211

99212

99213

99214

99215

G0237

G0238

G0239

Comprehensive outpatient PR programs may include: team assessment, individual training, psychosocial intervention, exercise training, and follow-up. An initial PR program up to 36 sessions may be considered medically necessary.

The PR program may include the following:

Team assessment:
- May include input from:
  - Physician; and
  - Respiratory care practitioner; and
  - Nurse; and
  - Psychologist; and
  - Others as needed.
Individual training:
- May include:
  - Breathing training; and
  - Bronchial hygiene; and
  - Medications; and
  - Proper Nutrition.
Psychosocial intervention:
- May address:
  - Support system; and
  - Dependency issues.
Exercise training:
- Includes strengthening and conditioning and may utilize the following:
  - Stair climbing; or
  - Inspiratory muscle training; or
  - Treadmill walking; or
  - Cycle training (with or without ergometer); or
  - Supported and unsupported arm exercise training.
- Note: Exercise conditioning is an essential component of pulmonary rehabilitation. Education in disease management techniques without exercise conditioning does not improve health outcomes of individuals who have chronic obstructive pulmonary disease.
Follow up:
- May include supervised home exercise conditioning.

An additional 36 sessions may be considered medically necessary upon review for a total of 72 lifetime sessions.

Quantity level limits (QLL) that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

Outpatient PR not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

94625

94626

94640

94664

94667

94668

94760

94761

97001

97002

97110

97116

97150

97161

97162

97163

97164

97530

97750

99205

99211

99212

99213

99214

99215

G0237

G0238

G0239

Diagnosis Codes

E84.0

J12.82

J41.0

J41.1

J41.8

J42

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.89

J44.9

J47.0

J47.1

J47.9

J60

J61

J62.0

J62.8

J63.0

J63.1

J63.2

J63.3

J63.4

J63.5

J63.6

J64

J65

J66.0

J66.1

J66.2

J66.8

J84.10

J84.170

J84.178

J84.89

J95.1

J95.2

J95.3

J95.821

J95.822

J96.00

J96.20

J96.21

J96.22

J98.2

J98.3

U07.1

U09.9

Z48.24

Z48.280

Z86.16

Z90.2

Z94.2

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Coding update: Removed J84.17; Added J84.170; J84.178; and S9473.

Internal Medical Policy Committee 11-19-2020 Revision- Removed section for indications for PR courses or programs are considered not medically necessary.

Internal Medical Policy Committee 1-19-2021 Coding update- Removed S8990; Added procedure code 99417; Statement added: Pulmonary Rehabilitation is a covered service for post COVID19; changes in verbiage.

Internal Medical Policy Committee 5-20-2021 Coding update Added diagnosis codes J12.82, U07.1, and Z86.16.

Internal Medical Policy Committee 7-22-2021 Revision-added for up to 18 sessions to PR program length.

Internal Medical Policy Committee 11-23-2021 Coding Update-Effective January 01, 2022, Adding procedure codes: 94625; 94626, and Removing G0424

Internal Medical Policy Committee 5-24-2022 updated with clarifying language and added diagnosis code U09.9

Internal Medical Policy Committee 11-23-2021 Coding Update-Effective October 01, 2023

Added diagnosis code J44.89

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: G-17-034

Section: Therapy

Effective Date: January 01, 2020

Revised Date: February 26, 2023

Revision Effective Date: May 01, 2023

Last Reviewed: March 23, 2023

Archived Date: September 30, 2023

Applies To: Commercial and Medicaid Expansion

Description

Individuals for PR should be medically stable and not limited by another serious or unstable medical condition. Contraindications to PR include but are not limited to:

Severe psychiatric disturbance (i.e., dementia, organic brain syndrome); or
Significant or unstable medical conditions (i.e., heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, or disabling stroke); or
Currently smoking.

Criteria

Pulmonary Rehabilitation is a covered service for post COVID-19.

A single course of PR in the outpatient ambulatory care setting may be considered medically necessary for ANY of the following indications:

Treatment of chronic pulmonary disease for individuals with moderate to severe disease (see Table ) who are experiencing disabling symptoms and significantly diminished QOL despite optimal medical management; or
Preoperative conditioning component for those considered appropriate candidates for lung volume reduction surgery or for lung transplantation; or
Following lung transplantation.

Outpatient PR not meeting the criteria as indicated in this policy is considered not medically necessary.

Table

Classification of Severity of Airflow Limitation in COPD a, b

GOLD 1

Mild

FEV1 greater than or equal to 80% predicted

GOLD 2

Moderate

50% less than or equal to FEV1 less than 80% predicted

GOLD 3

Severe

30% less than or equal to FEV1 less than 50% predicted

GOLD 4

Very Severe

FEV1 less than 30% predicted

a Based on post-bronchodilator FEV1

b In individuals with FEV1/FVC less than 0.70

Procedure Codes

94625

94626

94640

94664

94667

94668

94760

94761

97110

97116

97150

97161

97162

97163

97164

97530

97750

99205

99211

99212

99213

99214

99215

G0237

G0238

G0239

S9473

The PR program may include the following:

Team assessment:
- May include input from:
  - Physician; and
  - Respiratory care practitioner; and
  - Nurse; and
  - Psychologist; and
  - Others as needed.
Individual training:
- May include:
  - Breathing training; and
  - Bronchial hygiene; and
  - Medications; and
  - Proper Nutrition.
Psychosocial intervention:
- May address:
  - Support system; and
  - Dependency issues.
Exercise training:
- Includes strengthening and conditioning and may utilize the following:
  - Stair climbing; or
  - Inspiratory muscle training; or
  - Treadmill walking; or
  - Cycle training (with or without ergometer); or
  - Supported and unsupported arm exercise training.
- Note: Exercise conditioning is an essential component of pulmonary rehabilitation. Education in disease management techniques without exercise conditioning does not improve health outcomes of individuals who have chronic obstructive pulmonary disease.
Follow up:
- May include supervised home exercise conditioning.

An additional 36 sessions may be considered medically necessary upon review for a total of 72 lifetime sessions.

Quantity level limits (QLL) that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

Outpatient PR not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

94625

94626

94640

94664

94667

94668

94760

94761

97110

97116

97150

97161

97162

97163

97164

97530

97750

99205

99211

99212

99213

99214

99215

G0237

G0238

G0239

S9473

Diagnosis Codes

E84.0

J12.82

J41.0

J41.1

J41.8

J42

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.9

J47.0

J47.1

J47.9

J60

J61

J62.0

J62.8

J63.0

J63.1

J63.2

J63.3

J63.4

J63.5

J63.6

J64

J65

J66.0

J66.1

J66.2

J66.8

J84.10

J84.170

J84.178

J84.89

J95.1

J95.2

J95.3

J95.821

J95.822

J96.00

J96.20

J96.21

J96.22

J98.2

J98.3

U07.1

Z48.24

Z48.280

Z86.16

Z90.2

Z94.2

Z94.3

U09.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Coding update:

Removed J84.17; and
Added J84.170; J84.178; and S9473.

Internal Medical Policy Committee 11-19-2020 Revision-

Removed section for indications for PR courses or programs are considered not medically necessary

Internal Medical Policy Committee 1-19-2021 Coding update-

Removed S8990; and
Added procedure code 99417; and
Added statement: Pulmonary Rehabilitation is a covered service for post COVID19; changes in verbiage.

Internal Medical Policy Committee 5-20-2021 Coding update

Added diagnosis codes J12.82, U07.1, and Z86.16.

Internal Medical Policy Committee 7-22-2021 Revision-

Added for up to 18 sessions to PR program length.

Internal Medical Policy Committee 11-23-2021 Coding update-Effective January 01, 2022

Removed procedure code G0424; and
Added procedure codes: 94625; 94626

Internal Medical Policy Committee 5-24-2022

Updated with clarifying language; and
Added diagnosis code U09.9

Internal Medical Policy Committee 3-23-2023 Coding update - Effective March 23, 2023

Removed procedure codes 97001 and 97002

Links

References (PDF)

Disclaimer

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