Anthem Blue Cross Connecticut CG-REHAB-02 Outpatient Cardiac Rehabilitation Form

This document addresses cardiac rehabilitation services that are provided on an outpatient basis during the immediate post-discharge period and are considered Phase II cardiac rehabilitation programs (see Discussion/General Information section for further information related to the phases of Cardiac Rehabilitation Programs).

Medically Necessary:

Phase II cardiac rehabilitation is considered medically necessary when individually prescribed by a physician and the following criteria are met:

1. Cardiac rehabilitation is initiated within 12 months of ANY of the following:
   1. Acute myocardial infarction (MI); or
   2. Coronary artery bypass grafting (CABG); or
   3. Heart transplantation; or
   4. Percutaneous coronary intervention (that is, atherectomy, angioplasty, stenting); or
   5. Survivor of sudden cardiac death; or
   6. Survivor of sustained ventricular tachycardia or fibrillation; or
   7. Valve replacement or repair; or
   8. New York Heart Association (NYHA) Class II to IV congestive heart failure (CHF) that is interfering with the ability to perform age-related activities of daily living; or
   9. Coronary artery disease (CAD) with chronic stable angina pectoris that has failed to respond to pharmacotherapy and is interfering with the ability to perform age-related activities of daily living;
      and
2. 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);
   and
3. A formal exercise stress test has been completed following the qualifying cardiac event and prior to initiation of the rehabilitation program or, for individuals at low risk based on current symptoms, clinical features and exercise history, during the first rehabilitation session.

Not Medically Necessary:

The following are considered not medically necessary:

1. When the criteria above are not met;
2. Phase III cardiac rehabilitation programs, or self-directed, self-controlled or monitored exercise programs;
3. Phase IV cardiac rehabilitation programs or maintenance therapy that may be safely carried out without medical supervision;
4. Cardiac rehabilitation when used in a preventive or prophylactic way, such as for angina, hypertension, or diabetes.

Place of Service: Ambulatory, Outpatient Facility

Frequency/Duration:
The frequency and duration of treatment is determined by the following:

• The cardiac risk level; and
• The degree of exercise limitation as demonstrated by a treadmill electrocardiogram (ECG) stress test.

High Risk:
Individuals in the high-risk category may have ANY of the following:

• Exercise test limited to less than or equal to 5 metabolic equivalents (METS). (MET = a multiple of the resting energy expenditure, and is used as a means of estimating cardiac functional capacity. [1 MET = 3.5ml O2/kg body wt/min]); or
• Marked exercise-induced ischemia, as indicated by either anginal pain or 2 mm or more ST segment depression by ECG; or
• Severely depressed left ventricular function (ejection fraction less than 30%); or
• Resting complex ventricular arrhythmias; or
• Ventricular arrhythmias appearing or increasing with exercise or occurring in the recovery phase of stress testing; or
• Decrease in systolic blood pressure of greater than 15 mm Hg with exercise; or
• Recent myocardial infarction (less than 6 months) which was complicated by serious ventricular arrhythmias, cardiogenic shock, or congestive heart failure (CHF); or
• Survivor of sudden cardiac arrest.

Cardiac rehabilitation programs for high-risk individuals may include the following:

• 36 sessions (e.g., 3x/wk x 12 wks) of supervised exercise with continuous telemetry monitoring; and
• Educational program for risk factor/stress reduction; and
• Creation of an individual outpatient exercise program that can be self-monitored and maintained.

Note: If no clinically significant arrhythmia is documented during the first three weeks of the program, the remaining portion may be completed without telemetry monitoring.

Intermediate Risk:
Individuals in the intermediate risk category may have ANY of the following:

• Exercise test limited to 6-9 METS; or
• Ischemic ECG response to exercise of less than 2 mm of ST segment depression; or
• Uncomplicated myocardial infarction, coronary artery bypass surgery, or angioplasty and has a post-cardiac event maximal functional capacity of 8 METS or less on ECG exercise test.

Cardiac rehabilitation programs for intermediate risk individuals may include the following:

• Provide exercise training for 24 sessions or less of exercise training without continuous ECG monitoring (Note: Some individuals may require less than 3x/wk x 8 wks); and
• Be geared towards defining an ongoing exercise program that is self-administered.

Low Risk:
Individuals in the low risk category may have ANY of the following:

• Exercise test limited to greater than 9 METS; or
• Asymptomatic at rest.

Cardiac rehabilitation programs for low risk individuals may include the following:

• 6 one-hour sessions involving risk factor reduction education; and
• Supervised exercise to show safety and define a home program (for example 3x/week x 2wks or 2x/week x 3wks).

Additional cardiac rehabilitation services are considered medically necessary based on the above listed criteria in the event the individual has ANY of the following:

• Another documented myocardial infarction or extension of initial infarction; or
• Another cardiovascular surgery or angioplasty; or
• New evidence of ischemia on an exercise test, including thallium scan; or
• New clinically significant coronary lesions documented by cardiac catheterization.