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Outpatient Pulmonary Rehabilitation Form

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Outpatient Pulmonary Rehabilitation

Indications

(1) Does the request meet this criterion: Team assessment – input from physician, respiratory care practitioner, nurse, and psychologist, among others? 
(2) Does the request meet this criterion: Training – breathing retraining, education on bronchial hygiene, proper use of medications, and proper nutrition? 
(3) Does the request meet this criterion: Psychosocial intervention – addresses support system and dependency issues? 
(4) Does the request meet this criterion: Exercise training – strengthening and conditioning, which may include stair climbing, inspiratory muscle training, treadmill walking, cycle training with or without ergometer, and supported and unsupported arm exercise training. Exercise conditioning is an essential component of pulmonary? 
(5) Does the request meet this criterion: Physician-prescribed exercise: Aerobic exercise combined with other types of exercise (such as conditioning, breathing retraining, step, and strengthening) as determined to be appropriate for individuals by a physician, or nonphysician practitioner, must be included in each pulmonary? 

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 01|01|2020 POLICY LAST REVIEWED: 04|02|2025 OVERVIEW Pulmonary rehabilitation (PR) is a multidisciplinary approach to reducing symptoms and improving quality of life in individuals with compromised lung function. PR programs generally include an assessment followed by therapeutic interventions including exercise training, education, and behavior change. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Outpatient pulmonary rehabilitation is covered.
Home-based pulmonary rehabilitation programs are not covered for all Blue Cross & Blue Shield of Rhode Island (BCBSRI) products. Medicare Advantage Plans Outpatient pulmonary rehabilitation beyond one course of treatment is typically not covered as the individual is expected to have been taught the appropriate self-care.
Commercial Products Outpatient pulmonary rehabilitation beyond one course of treatment is typically not medically necessary as the individual is expected to have been taught the appropriate self-care.
COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable Respiratory Therapy benefits/coverage. BACKGROUND In 2013, the American Thoracic Society and the European Respiratory Society defined pulmonary rehabilitation (PR) as a “comprehensive intervention based on a thorough assessment followed by tailored therapies that include, but are not limited to exercise training, education, and behavior change.” PR programs are intended to improve functioning and quality of life. Most research has focused on individuals with chronic obstructive pulmonary disease, although there has been some interest in individuals with asthma, cystic fibrosis, or bronchiectasis. PR is also routinely offered to individuals awaiting lung transplantation and lung volume reduction surgery. PR before lung surgery may stabilize or improve exercise tolerance, teach techniques that will help them recover after the procedure, and allow health care providers to identify individuals who might be suboptimal surgical candidates due to noncompliance, poor health, or other reasons. Pulmonary rehabilitation programs are intended to improve functioning and quality of life and include exercise training, psychosocial support, and/or education. Programs typically include the following: Medical Coverage Policy | Outpatient Pulmonary Rehabilitation

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

• Team assessment – input from physician, respiratory care practitioner, nurse, and psychologist, among others • Training – breathing retraining, education on bronchial hygiene, proper use of medications, and proper nutrition • Psychosocial intervention – addresses support system and dependency issues • Exercise training – strengthening and conditioning, which may include stair climbing, inspiratory muscle training, treadmill walking, cycle training with or without ergometer, and supported and unsupported arm exercise training. 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.

Candidates for pulmonary rehabilitation should be medically stable and not limited by another serious or unstable medical condition. Contraindications to pulmonary rehabilitation include severe psychiatric disturbance (e.g., dementia, organic brain syndrome), and significant or unstable medical conditions (e.g., heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, disabling stroke).

A course of treatment typically consists of two 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions over an extended period of time (not to exceed 72 sessions) when program requirements are met.

According to Medicare Claims Processing Manual Chapter 32 – Billing Requirements for Special Services, as specified in 42 CFR 410.47, Medicare covers pulmonary rehabilitation items and services for individuals with moderate to very severe COPD (defined as GOLD classification II, III, and IV) when referred by the physician treating the chronic respiratory disease, or individuals who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks.

Pulmonary rehabilitation programs must include the following components:
• Physician-prescribed exercise: Aerobic exercise combined with other types of exercise (such as conditioning, breathing retraining, step, and strengthening) as determined to be appropriate for individuals by a physician, or nonphysician practitioner, must be included in each pulmonary rehabilitation session;
• Education or training closely and clearly related to the individual’s care and treatment that is tailored to the individual’s needs and assists in achievement of goals toward independence in activities of daily living, adaptation to limitations and improved quality of life; including information on respiratory problem management and, if appropriate, brief smoking cessation counseling;
• Psychosocial assessment;
• Outcomes assessment; and,
• An individualized treatment plan detailing how components are utilized for each individual.

Pulmonary rehabilitation items and services must be furnished in a physician’s office or a hospital outpatient setting. All settings must have a physician, or nonphysician practitioner, immediately available and accessible for medical consultations and emergencies at all times items and services are being furnished under the program.

CODING Medicare Advantage Plans and Commercial Products The following code(s) are covered:
94625 Physician or other qualified health care professional services for outpatient pulmonary rehabilitation;
without continuous oximetry monitoring (per session) 94626 physician or other qualified health care professional services for outpatient pulmonary rehabilitation;
with continuous oximetry monitoring (per session) S9473 Pulmonary rehabilitation program, non-physician provider, per diem

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

For correct claims processing, claims should not include the following HCPCS code(s). Instead, the codes listed above should be used: G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes (includes monitoring) G0238 Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring) G0239 Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)

RELATED POLICIES Non-Reimbursable Health Service Codes

PUBLISHED Provider Update, June 2025 Provider Update, July 2024 Provider Update, May 2023 Provider Update, July 2022 Provider Update, June 2021

REFERENCES

  1. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Pulmonary Rehabilitation Services (240.8). 2008; https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCAId=130&NcaName=Smoking+%26+Tobacco+Use+Cessation+Counseling&ExpandC omments=n&CommentPeriod=0&NCDId=320&NCSelection=NCA%7CCAL%7CNCD%7CMEDCA C%7CTA%7CMCD&KeyW. Accessed March 12, 2024.
  2. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. Oct 15 2013; 188(8): e13-64. PMID 24127811
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  13. Yu X, Li X, Wang L, et al. Pulmonary Rehabilitation for Exercise Tolerance and Quality of Life in IPF Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2019; 2019: 8498603. PMID 31016200

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

  1. Cheng L, Tan B, Yin Y, et al. Short- and long-term effects of pulmonary rehabilitation for idiopathic pulmonary fibrosis: a systematic review and meta-analysis. Clin Rehabil. Oct 2018; 32(10): 1299-1307. PMID 29843523
  2. Lee AL, Hill CJ, McDonald CF, et al. Pulmonary Rehabilitation in Individuals With Non-Cystic Fibrosis Bronchiectasis: A Systematic Review. Arch Phys Med Rehabil. Apr 2017; 98(4): 774-782.e1. PMID 27320420
  3. Araújo AS, Figueiredo MR, Lomonaco I, et al. Effects of Pulmonary Rehabilitation on Systemic Inflammation and Exercise Capacity in Bronchiectasis: A Randomized Controlled Trial. Lung. Jun 2022; 200(3): 409-417. PMID 35543710
  4. Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. May 22 2003; 348(21): 2059-73. PMID 12759479
  5. Hoffman M, Chaves G, Ribeiro-Samora GA, et al. Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review. BMJ Open. Feb 03 2017; 7(2): e013445. PMID 28159852
  6. Morano MT, Araújo AS, Nascimento FB, et al. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. Arch Phys Med Rehabil. Jan 2013; 94(1): 53-8. PMID 22926460
  7. Benzo R, Wigle D, Novotny P, et al. Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Lung Cancer. Dec 2011; 74(3): 441-5. PMID 21663994
  8. Bradley A, Marshall A, Stonehewer L, et al. Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery. Eur J Cardiothorac Surg. Oct 2013; 44(4): e266-71. PMID 23959742
  9. Beling J. Improved health-related quality of life after lung volume reduction surgery and pulmonary rehabilitation. Cardiopulm Phys Ther J. Sep 2009; 20(3): 16-22. PMID 20467519
  10. Wickerson L, Mathur S, Brooks D. Exercise training after lung transplantation: a systematic review. J Heart Lung Transplant. May 2010; 29(5): 497-503. PMID 20133160
  11. Langer D, Burtin C, Schepers L, et al. Exercise training after lung transplantation improves participation in daily activity: a randomized controlled trial. Am J Transplant. Jun 2012; 12(6): 1584-92. PMID 22390625
  12. Fuller LM, Button B, Tarrant B, et al. Longer Versus Shorter Duration of Supervised Rehabilitation After Lung Transplantation: A Randomized Trial. Arch Phys Med Rehabil. Feb 2017; 98(2): 220-226.e3. PMID 27697429
  13. Munro PE, Holland AE, Bailey M, et al. Pulmonary rehabilitation following lung transplantation. Transplant Proc. 2009; 41(1): 292-5. PMID 19249538
  14. Stigt JA, Uil SM, van Riesen SJ, et al. A randomized controlled trial of postthoracotomy pulmonary rehabilitation in patients with resectable lung cancer. J Thorac Oncol. Feb 2013; 8(2): 214-21. PMID 23238118
  15. Edvardsen E, Skjønsberg OH, Holme I, et al. High-intensity training following lung cancer surgery: a randomised controlled trial. Thorax. Mar 2015; 70(3): 244-50. PMID 25323620
  16. Dillen H, Bekkering G, Gijsbers S, et al. Clinical effectiveness of rehabilitation in ambulatory care for patients with persisting symptoms after COVID-19: a systematic review. BMC Infect Dis. Jun 21 2023; 23(1): 419. PMID 37344767
  17. Calvache-Mateo A, Heredia-Ciuró A, Martín-Núñez J, et al. Efficacy and Safety of Respiratory Telerehabilitation in Patients with Long COVID-19: A Systematic Review and Meta-Analysis. Healthcare (Basel). Sep 12 2023; 11(18). PMID 37761716
  18. Pescaru CC, Crisan AF, Marc M, et al. A Systematic Review of Telemedicine-Driven Pulmonary Rehabilitation after the Acute Phase of COVID-19. J Clin Med. Jul 24 2023; 12(14). PMID 37510969
  19. Carr SJ, Hill K, Brooks D, et al. Pulmonary rehabilitation after acute exacerbation of chronic obstructive pulmonary disease in patients who previously completed a pulmonary rehabilitation program. J Cardiopulm Rehabil Prev. 2009; 29(5): 318-24. PMID 19561523
  20. COPD Working Group. Pulmonary rehabilitation for patients with chronic pulmonary disease (COPD): an evidence-based analysis. Ont Health Technol Assess Ser. 2012; 12(6): 1-75. PMID 23074434
  21. Güell MR, Cejudo P, Ortega F, et al. Benefits of Long-Term Pulmonary Rehabilitation Maintenance Program in Patients with Severe Chronic Obstructive Pulmonary Disease. Three-Year Follow-up. Am J Respir Crit Care Med. Mar 01 2017; 195(5): 622-629. PMID 27611807

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

  1. Wilson AM, Browne P, Olive S, et al. The effects of maintenance schedules following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomised controlled trial. BMJ Open. Mar 11 2015; 5(3): e005921. PMID 25762226
  2. Liu XL, Tan JY, Wang T, et al. Effectiveness of home-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a meta-analysis of randomized controlled trials. Rehabil Nurs. 2014; 39(1): 36-59. PMID 23780865
  3. Vieira DS, Maltais F, Bourbeau J. Home-based pulmonary rehabilitation in chronic obstructive pulmonary disease patients. Curr Opin Pulm Med. Mar 2010; 16(2): 134-43. PMID 20104176
  4. Stafinski T, Nagase FI, Avdagovska M, et al. Effectiveness of home-based pulmonary rehabilitation programs for patients with chronic obstructive pulmonary disease (COPD): systematic review. BMC Health Serv Res. Apr 26 2022; 22(1): 557. PMID 35473597
  5. Neves LF, Reis MH, Gonçalves TR. Home or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Cad Saude Publica. Jun 20 2016; 32(6). PMID 27333130
  6. Maltais F, Bourbeau J, Shapiro S, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. Dec 16 2008; 149(12): 869-78. PMID 19075206
  7. Rochester CL, Vogiatzis I, Holland AE, et al. An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation. Am J Respir Crit Care Med. Dec 01 2015; 192(11): 1373-86. PMID 26623686
  8. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. Mar 2017; 49(3). PMID 28298398
  9. Holland AE, Cox NS, Houchen-Wolloff L, et al. Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc. May 2021; 18(5): e12-e29. PMID 33929307
  10. Rochester CL, Alison JA, Carlin B, et al. Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. Aug 15 2023; 208(4): e7-e26. PMID 37581410
  11. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease. 2024. https://goldcopd.org/2024-gold-report/. Accessed January 22, 2025.

  12. National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: managing the long- term effects of COVID-19 [NG188]. November 11, 2021; https://www.nice.org.uk/guidance/ng188. Accessed January 21, 2025.

    i

    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. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS

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