Anthem Blue Cross Connecticut CG-REHAB-03 Pulmonary Rehabilitation Form

This document addresses the use of pulmonary rehabilitation for the treatment of various lung conditions. Pulmonary rehabilitation (PR) is an individually tailored multidisciplinary program of care for people with chronic respiratory impairment.

Clinical Indications

Medically Necessary:

Pulmonary rehabilitation (PR) is considered medically necessary in individuals who meet the following criteria:

1. Individual is preparing for or recovering from surgical interventions such as:
   1. Lung transplantation; or
   2. Lung volume reduction surgery; or
   3. Post-operative states; (for example, thoracic or abdominal surgery).
      or
2. Individual has any of the following conditions:
   1. Chronic obstructive pulmonary disease such as:
      1. Asthma; or
      2. Bronchiectasis; or
      3. Chronic bronchitis; or
      4. Cystic fibrosis; or
      5. Emphysema; or
   2. Restrictive diseases such as:
      1. Chest wall disease; or
      2. Interstitial disease; or
      3. Post-polio syndrome; or
      4. Selected neuromuscular disorders; or
      5. Thoracic cage abnormalities; or
   3. Stable lung cancer;
      and
3. Individual continues to have disabling dyspnea despite optimal medical management associated with the following:
   1. A restriction in ordinary activities: and
   2. Significant impairment in quality of life;
      and
4. Individual is motivated to participate in a PR program;
   and
5.  Individual is free from the following (1 and 2 below):
   1. Conditions that may interfere with the individual undergoing the rehabilitative process, including but not limited to:
      1. Advanced arthritis; or
      2. Disruptive behavior; or
      3. Inability to learn;
         and
   2. Conditions that may place the individual at undue risk during exercise training, including but not limited to:
      1. Recent myocardial infarction; or
      2. Severe pulmonary hypertension; or
      3. Unstable angina.

Repeat PR programs may be considered medically necessary for individuals undergoing a second PR program in connection with lung transplantation or lung volume reduction surgery when medical necessity criteria for PR are met.

Not Medically Necessary:

PR provided in the inpatient setting is considered not medically necessary when medical necessity criteria for PR are not met.

Place of Service/Duration

Place of Service: Ambulatory/Outpatient
Duration: Frequency and duration of the program may vary according to the individual’s needs. It is not uncommon for the individual to receive therapy 3 times per week for 4 to 6 weeks.