136 Form

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Medical Policy Outpatient Pulmonary Rehabilitation Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 136 BCBSA Reference Number: 8.03.05 (For Plan internal use only) Related Policies • Lung and Lobar Lung Transplant, #015 • Heart/ Lung Transplant, #269 • Lung Volume Reduction Surgery for Severe Emphysema, #364 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

A single course of pulmonary rehabilitation in the outpatient ambulatory care setting may be MEDICALLY NECESSARY for treatment of chronic pulmonary disease for individuals with moderate to severe disease who are experiencing disabling symptoms and significantly diminished quality of life despite optimal medical management.

A single course of pulmonary rehabilitation may be MEDICALLY NECESSARY in an outpatient ambulatory care setting as a preoperative conditioning component for those considered appropriate candidates for lung volume reduction surgery or for lung transplantation.

Pulmonary rehabilitation programs are considered MEDICALLY NECESSARY following lung transplantation.

Pulmonary rehabilitation programs are considered INVESTIGATIONAL following other types of lung surgery, included but not limited to lung volume reduction surgery and surgical resection of lung cancer.

Multiple courses of pulmonary rehabilitation are considered is INVESTIGATIONAL, either as maintenance therapy in individuals who initially respond, or in individuals who fail to respond, or whose response to an initial rehabilitation program has diminished over time.

Home-based pulmonary rehabilitation programs are INVESTIGATIONAL.

Pulmonary rehabilitation programs are INVESTIGATIONAL in all other situations.

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Pulmonary rehabilitation in the outpatient ambulatory setting is NOT MEDICALLY NECESSARY for patients with severe psychiatric disturbance (e.g., dementia, organic brain syndrome), and significant or unstable medical conditions (e.g., congestive heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, disabling stroke).

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT codes: Code Description 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)

HCPCS Codes HCPCS codes: Code Description 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)
G0302 Preoperative pulmonary surgery services for preparation for LVRS, complete course of services, to include a minimum of 16 days of services G0303 Preoperative pulmonary surgery services for preparation for LVRS, 10 to 15 days of services

3 G0304 Preoperative pulmonary surgery services for preparation for LVRS, 1 to 9 days of services G0305 Post discharge pulmonary surgery services after LVRS, minimum of 6 days of services G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day S9473 Pulmonary rehabilitation program, nonphysician provider, per diem The following ICD Diagnosis Codes are considered medically necessary when submitted with the HCPCS codes above if medical necessity criteria are met: ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description D38.1 Neoplasm of uncertain behavior of trachea, bronchus and lung D84.1 Defects in the complement system D86.0 Sarcoidosis of lung D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes D86.87 Sarcoid myositis D86.9 Sarcoidosis, unspecified E84.0 Cystic fibrosis with pulmonary manifestations E84.9 Cystic fibrosis, unspecified I26.01 Septic pulmonary embolism with acute cor pulmonale I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale I26.03 Cement embolism of pulmonary artery with acute cor pulmonale I26.04 Fat embolism of pulmonary artery with acute cor pulmonale I26.09 Other pulmonary embolism with acute cor pulmonale I26.90 Septic pulmonary embolism without acute cor pulmonale I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale I26.95 Cement embolism of pulmonary artery without acute cor pulmonale I26.96 Fat embolism of pulmonary artery without acute cor pulmonale I26.99 Other pulmonary embolism without acute cor pulmonale I27.0 Primary pulmonary hypertension J22 Unspecified acute lower respiratory infection J41.0 Simple chronic bronchitis J41.1 Mucopurulent chronic bronchitis J41.8 Mixed simple and mucopurulent chronic bronchitis J42 Unspecified chronic bronchitis J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome] J43.1 Panlobular emphysema J43.2 Centrilobular emphysema J43.8 Other emphysema J43.9 Emphysema, unspecified J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified J47.0 Bronchiectasis with acute lower respiratory infection J47.1 Bronchiectasis with (acute) exacerbation J47.9 Bronchiectasis, uncomplicated J68.4 Chronic respiratory conditions due to chemicals, gases, fumes and vapors J70.1 Chronic and other pulmonary manifestations due to radiation

4 J70.2 Acute drug-induced interstitial lung disorders J70.3 Chronic drug-induced interstitial lung disorders J70.4 Drug-induced interstitial lung disorders, unspecified J70.5 Respiratory conditions due to smoke inhalation J70.8 Respiratory conditions due to other specified external agents J70.9 Respiratory conditions due to unspecified external agent J84.10 Pulmonary fibrosis, unspecified J84.111 Idiopathic interstitial pneumonia, not otherwise specified J84.112 Idiopathic pulmonary fibrosis J84.113 Idiopathic non-specific interstitial pneumonitis J84.114 Acute interstitial pneumonitis J84.115 Respiratory bronchiolitis interstitial lung disease J84.116 Cryptogenic organizing pneumonia J84.117 Desquamative interstitial pneumonia J84.170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere J84.178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere J84.2 Lymphoid interstitial pneumonia J84.89 Other specified interstitial pulmonary diseases J95.3 Chronic pulmonary insufficiency following surgery J95.822 Acute and chronic postprocedural respiratory failure J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia J96.11 Chronic respiratory failure with hypoxia J96.12 Chronic respiratory failure with hypercapnia J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia J96.21 Acute and chronic respiratory failure with hypoxia J96.22 Acute and chronic respiratory failure with hypercapnia J98.2 Interstitial emphysema J98.3 Compensatory emphysema J98.4 Other disorders of lung J98.8 Other specified respiratory disorders J99 Respiratory disorders in diseases classified elsewhere M32.13 Lung involvement in systemic lupus erythematosus M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.11 Other dermatopolymyositis with respiratory involvement M33.21 Polymyositis with respiratory involvement M33.91 Dermatopolymyositis, unspecified with respiratory involvement M34.0 Progressive systemic sclerosis M34.1 CR(E)ST syndrome M34.2 Systemic sclerosis induced by drug and chemical M34.81 Systemic sclerosis with lung involvement M34.82 Systemic sclerosis with myopathy M34.83 Systemic sclerosis with polyneuropathy M34.89 Other systemic sclerosis M34.9 Systemic sclerosis, unspecified M35.02 Sicca syndrome with lung involvement P27.0 Wilson-Mikity syndrome P27.1 Bronchopulmonary dysplasia originating in the perinatal period P27.8 Other chronic respiratory diseases originating in the perinatal period P27.9 Unspecified chronic respiratory disease originating in the perinatal period Q21.0 Ventricular septal defect

5 Q33.4 Congenital bronchiectasis T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial encounter Z48.24 Encounter For Aftercare Following Lung Transplant Z94.2 Lung Transplant Status

Description Pulmonary Rehabilitation In 2013, the American Thoracic Society and the European Respiratory Society defined pulmonary rehabilitation as a “comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to exercise training, education, and behavior change.”1, Pulmonary rehabilitation programs are intended to improve patient functioning and quality of life. Most research has focused on patients with chronic obstructive pulmonary disease, although there has been some interest in patients with asthma, cystic fibrosis, or bronchiectasis.

Summary Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life in patients with compromised lung function. Pulmonary rehabilitation programs generally include a patient assessment followed by therapeutic interventions including exercise training, education, and behavior change.

Summary of Evidence Chronic Pulmonary Disease Rehabilitation For individuals with moderate-to-severe chronic obstructive pulmonary disease (COPD) who receive a single course of outpatient pulmonary rehabilitation, the evidence includes numerous systematic reviews of randomized controlled trials (RCTs). Relevant outcomes are symptoms, functional outcomes, and quality of life. The published studies found improved outcomes (ie, functional ability, quality of life) in patients with moderate-to-severe COPD who underwent a comprehensive pulmonary rehabilitation program in the outpatient setting. Among the many randomized trials, the structure of the pulmonary rehabilitation programs varied, so it is not possible to provide guidance on the optimal components or duration of a pulmonary rehabilitation program. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with idiopathic pulmonary fibrosis who receive a single course of outpatient pulmonary rehabilitation, the evidence includes 3 systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, and quality of life. Significant differences favoring pulmonary rehabilitation over usual care were seen in 6-minute walk distance (6MWD) in the short term. Starting at 3 months post- intervention, outcomes did not differ between groups. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with bronchiectasis who receive a single course of outpatient pulmonary rehabilitation, the evidence includes a systematic review of RCTs and an RCT published after the systematic review. Relevant outcomes are symptoms, functional outcomes, and quality of life. The systematic review included 4 RCTs on pulmonary rehabilitation for patients with bronchiectasis found that some, but not all, outcomes, improved more with pulmonary rehabilitation than with nonexercise control conditions immediately after the intervention. An RCT published after the systematic review found that 6MWT and quality of life scores increased with pulmonary rehabilitation compared to a non-exercise control group in the short-term. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Although most published evidence on outpatient pulmonary rehabilitation for chronic pulmonary diseases assesses COPD, observational studies have reported on outcomes from pulmonary rehabilitation for other chronic pulmonary diseases. Clinical guidelines from pulmonary organizations have supported the use of outpatient pulmonary rehabilitation for individuals who are experiencing disabling symptoms and

6 have significantly diminished quality of life despite optimal medical management. Therefore, outpatient pulmonary rehabilitation may be considered medically necessary for this population.

Preparation for Lung Surgery For individuals with scheduled lung surgery for volume reduction, transplantation, or resection who receive a single course of preoperative outpatient pulmonary rehabilitation, the evidence includes RCTs and observational studies. Relevant outcomes are symptoms, functional outcomes, and quality of life. There is a lack of large RCTs comparing pulmonary rehabilitation with no pulmonary rehabilitation for preoperative candidates undergoing lung volume reduction surgery, lung transplantation, or lung cancer resection. Moreover, the available studies have evaluated exercise programs, but not necessarily comprehensive pulmonary rehabilitation programs. Also, the few small RCTs and observational studies have only reported short-term outcomes and there was inconsistent evidence of benefit on these outcomes. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Findings from the National Emphysema Treatment Trial have suggested that pulmonary rehabilitation is an appropriate component of care for patients with COPD before undergoing lung volume reduction surgery. Also, pulmonary rehabilitation is considered the standard of care in individuals undergoing lung transplantation to maximize preoperative pulmonary status. Thus, pulmonary rehabilitation may be considered medically necessary for individuals considered appropriate candidates for lung volume reduction surgery or lung transplantation.

Pulmonary Rehabilitation After Lung Surgery For individuals who have had lung volume reduction surgery who receive a single course of outpatient pulmonary rehabilitation, the evidence includes a case series. Relevant outcomes are symptoms, functional outcomes, and quality of life. No published RCTs were identified. The case series evaluated a comprehensive pulmonary rehabilitation program after lung volume reduction surgery in 49 patients who had not received preoperative pulmonary rehabilitation. Health-related quality of life was higher at 3 to 6 months and 12 to 18 months post-surgery. The series did not provide data on patients who underwent lung volume reduction surgery and did not have postoperative pulmonary rehabilitation, or patients who had preoperative pulmonary rehabilitation. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have had lung transplantation who receive a single course of outpatient pulmonary rehabilitation, the evidence includes RCTs, a systematic review, and a case series. Relevant outcomes are symptoms, functional outcomes, and quality of life. Neither of the 2 RCTs identified in a 2010 systematic review reported on functional outcomes, but uncontrolled studies have reported improvements in functional outcomes. An RCT, published after the systematic review, found that patients who had a postsurgical exercise intervention walked more 1-year postdischarge than before and had a significantly greater 6MWD. Findings on other outcomes were mixed. The most recent RCT (2017) did not identify a difference in outcomes with longer duration of pulmonary rehabilitation. Case series data also support improvements in 6MWD after postoperative pulmonary rehabilitation. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have had lung cancer resection who receive a single course of outpatient pulmonary rehabilitation, the evidence includes 2 RCTs. Relevant outcomes are symptoms, functional outcomes, and quality of life. One small RCT evaluated a comprehensive pulmonary rehabilitation program in patients who underwent thoracotomy for lung cancer. The trial was terminated early, had a high dropout rate, and reported mixed findings. An exercise-only intervention in patients who had lung cancer surgery had mixed findings and did not evaluate functional outcomes. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Repeat or Maintenance Pulmonary Rehabilitation For individuals who have had an initial course of pulmonary rehabilitation who receive repeat or maintenance outpatient pulmonary rehabilitation, the evidence includes a limited number of RCTs. Relevant outcomes are symptoms, functional outcomes, and quality of life. One small

7 RCT evaluating repeat pulmonary rehabilitation programs had methodologic limitations and did not report inpatient and outpatient outcomes separately; it also lasted only 3 weeks. In the evaluation of maintenance pulmonary rehabilitation programs, evidence was mixed. Due to the paucity of RCTs, methodologic limitations of available trials, and lack of clinically significant findings, the evidence to determine the effect of maintenance pulmonary rehabilitation programs on health outcomes in patients with COPD is insufficient. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Home-Based Pulmonary Rehabilitation For individuals who have an indication for outpatient pulmonary rehabilitation who receive a single course of home-based pulmonary rehabilitation, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, functional outcomes, and quality of life. Most studies of home-based pulmonary rehabilitation have compared outcomes with standard care. Very few have compared home-based pulmonary rehabilitation with the hospital- or clinic-based pulmonary rehabilitation, and the available studies are mostly of low quality. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 4/2026 Policy updated with literature review through January 22, 2026; references added. Policy statements unchanged. 5/2025 Annual policy review. References updated. Policy statements unchanged. 12/2024 Clarified coding information. 10/2024 Clarified coding information. 5/2023 Annual policy review. Minor editorial refinements to policy statements; intent unchanged. 4/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2021 Annual policy review. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
10/2020 Clarified coding information 5/2020 Annual policy review. Description, summary and references updated. Policy statements unchanged. 4/2019 Annual policy review. Description, summary and references updated. Policy statements unchanged. 5/2018 Annual policy review. Policy statements reordered to align with the summary. Prior Authorization Information reformatted. Policy statements unchanged. 2/2018 Clarified coding information. 10/2017 Clarified coding information.
4/2016 New references added from Annual policy review. 7/2015 Annual policy review. In summary, “lung resection surgery” corrected to “lung volume reduction surgery.” 6/2015 Annual policy review. New medically necessary and investigational indications described. Effective 6/1/2015. 11/2014 Clarified coding information. 6/2014 Annual policy review. New investigational indications described. Effective 6/1/2014. 5/2014 Updated Coding section with ICD10 procedure and diagnosis codes/. Effective 10/2015. 4/2014 Coding information clarified. 2/2013 New references from Annual policy review. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
4/2011 Reviewed - Medical Policy Group – Cardiology and Pulmonology. No changes to policy statements.

8 3/2010 Reviewed - Medical Policy Group - Pulmonology, Allergy/Asthma/Immunology, ENT and Otolaryngology. No changes to policy statements.
11/1/2009 Medical Policy 136 effective 11/1/09 describing covered and non-covered indications. 6/2007 Annual policy review. No changes to policy statement. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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