Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 02|01|2009 POLICY LAST UPDATED: 04|07|2021

OVERVIEW Cardiac rehabilitation 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.
MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
Not applicable

POLICY STATEMENT Medicare Advantage Plans Cardiac rehabilitation services and intensive cardiac rehabilitation services are covered.

Commercial Products Cardiac rehabilitation services, including intensive cardiac rehabilitation services, are covered. Benefit is limited per episode. See the specific Subscriber Agreement; there is no extended coverage per episode.

Medicare Advantage Plans and Commercial Products Maintenance programs that follow the initial rehabilitation program are not covered for all products.

Education services, defined as counseling on diet, nutrition, lipid levels, stress management, and lifestyle changes (including daily exercise), are included as part of the cardiac rehabilitation program and are not reimbursed as a separate component and are not separately reimbursed for all products.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement, for the applicable Cardiac Rehabilitation benefits/coverage.

BACKGROUND Heart disease is the leading cause of mortality in the United States, accounting for more than half of all deaths. Coronary artery disease is the most common cause of heart disease. In a 2015 update on heart disease and stroke statistics from the American Heart Association, it was estimated that 635,000 Americans have a new coronary attack (first hospitalized myocardial infarction or coronary heart disease death) and 300,000 have a recurrent attack annually. Both coronary artery disease and various other disorders—structural heart disease and other genetic, metabolic, endocrine, toxic, inflammatory, and infectious causes—can lead to the clinical syndrome of heart failure, of which there are about 650,000 new cases in the United States annually. Given the burden of heart disease, preventing secondary cardiac events and treating the symptoms of heart disease and heart failure have received much attention from national organizations.

Cardiac rehabilitation services are typically for patients who have had the following: • An acute myocardial infarction within the preceding 12 months; or
• Coronary artery bypass surgery; or
Payment Policy | Cardiac Rehabilitation

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

• Current stable angina pectoris; or
• Heart valve repair or replacement; or
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
• A heart or heart-lung transplant, or
• Stable, chronic heart failure, as defined below*

If the member has participated in cardiac rehabilitation in the past, a new cardiac episode as defined above, or a change in one of the conditions listed would be required to qualify for an additional series of cardiac rehabilitation, e.g., a stable congestive heart failure (CHF) patient who experiences decompensation would again meet the criteria for cardiac rehabilitation once stable and able to tolerate the rehabilitation.

INTENSIVE CARDIAC REHABILITATION (ICR) Intensive cardiac rehabilitation (ICR) refers to a physician-supervised program that furnishes cardiac rehabilitation services more frequently and often in a more rigorous manner. As required by §1861(eee)(4)(A) of the Social Security Act (the Act), an ICR program must show, in peer-reviewed published research, that it accomplished one or more of the following for its patients: (1) positively affected the progression of coronary heart disease; (2) reduced the need for coronary bypass surgery; and, (3) reduced the need for percutaneous coronary interventions. The ICR program must also demonstrate through peer-reviewed published research that it accomplished a statistically significant reduction in five or more of the following measures for patients from their levels before cardiac rehabilitation services to after cardiac rehabilitation services: (1) low density lipoprotein; (2) triglycerides; (3) body mass index; (4) systolic blood pressure; (5) diastolic blood pressure; and, (6) the need for cholesterol, blood pressure, and diabetes medications. Individual ICR programs must be approved through the national coverage determination process to ensure that they demonstrate these accomplishments. CMS has determined that the Ornish Program for Reversing Heart Disease, the Pritikin Program and the Benson-Henry Institute Cardiac Wellness Program each meet the ICR program requirements.

*Effective for dates of service on and after February 18, 2014, the Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is sufficient to expand coverage for cardiac rehabilitation services under 42 CFR §410.49(b)(1)(vii) to beneficiaries with stable, chronic heart failure, defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks. Stable patients are defined as patients who have not had recent (< or equal to 6 weeks) or planned (< or equal to 6 months) major cardiovascular hospitalizations or procedures.

CODING Medicare Advantage Plans: The following CPT codes are covered: 93797 Physician or other qualified health care professional services for outpatient cardiac

         rehabilitation; without continuous ECG monitoring (per session)

93798 Physician or other qualified health care professional services for outpatient cardiac rehabilitation;

         with continuous ECG monitoring (per session)

G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise,

         per session

G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise,

         per session

Commercial Products: The following CPT codes are covered for all cardiac rehabilitation programs including intensive cardiac rehabilitation programs: 93797 Physician or other qualified health care professional services for outpatient cardiac

         rehabilitation; without continuous ECG monitoring (per session)

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

93798 Physician or other qualified health care professional services for outpatient cardiac rehabilitation;

         with continuous ECG monitoring (per session)

The following HCPCS codes are not applicable for Commercial claims. Claims for intensive cardiac rehabilitation programs must be filed with one of the CPT codes above: G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise,

         per session

G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise,

         per session

Medicare Advantage Plans and Commercial Products: The following CPT code is not separately reimbursed: 99078 Physician or other qualified health care professional qualified by education,

        training, licensure/regulation (when applicable) educational services rendered to patients  
        in a group setting (eg, prenatal, obesity, or diabetic instructions)

RELATED POLICIES Not applicable

PUBLISHED Provider Update, June 2021 Provider Update, October 2019 Provider Update, February 2019 Provider Update, July 2017 Provider Update, May 2016

REFERENCES 1.Centers for Medicare % Medicaid Services (CMS). National Coverage Determination (NCD) for Intensive Cardiac Rehabilitation Programs (20.31). 2010; http://www.cms.gov/medicare-coverage- database/details/ncd- details.aspx?NCDId=339&ncdver=1&CoverageSelection=National&KeyWord=intensive+cardiac&KeyWor dLook Up=Title&KeyWordSearchType=And&clickon=search&bc=gAAAABAAAAAA&. Accessed February 10, 2020. 2.Centers for Medicare & Medicaid Services (CMS). CMS Manual System: Pub 100-03 Medicare National Coverage Determinations. Cardiac Rehabilitation Programs for Chronic Heart Failure. 2014; https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=359&ncdVer=1. Accessed February 10, 2020. 3.Centers for Medicare & Medicaid Services (CMS). Decision Memo for INTENSIVE CARDIAC Rehabilitation (ICR) Program - Dr. Ornish's Program for Reversing Heart Disease (CAG-00419N). 2010; https://www.cms.gov/medicare-coverage-database/details/nca-decision- memo.aspx?NCAId=240&NCDId=339&ncdver=1&CoverageSelection=National&KeyWord=intensive+car diac&K eyWordLookUp=Title&KeyWordSearchType=And&clickon=search&IsPopup=y&bc=AAAAAAAACAAA AA%3d%3 d&. Accessed February 10, 2020.

4. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. Jan 27 2015;131(4):e29-322. PMID 25520374
5. Yancy CW, Jessup M, Bozkurt B et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128(16):1810-52.
6. Taylor RS, Sagar VA, Davies EJ, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014;4:CD003331. PMID 24771460
7. Corra U, Piepoli MF, Carre F et al. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2010; 31(16):1967-74.

8. Leon AS, Franklin BA, Costa F et al. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease: An American Heart Association Scientific Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2005; 111(3):369-76.

9. Heart Failure Society of America. Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):475-539. 10.. Oldridge N. Exercise-based cardiac rehabilitation in patients with coronary heart disease: meta-analysis outcomes revisited. Future Cardiol. Sep 2012;8(5):729-751. PMID 23013125

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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