Description

Pulmonary rehabilitation (rehab) is a comprehensive intervention based on a thorough individualized assessment followed by individually tailored therapies, which include, but are not limited to, exercise training, education and behavior change, designed to improve the physical and psychological condition of an individual with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.

Pulmonary rehab is usually conducted in an outpatient setting. Components consist of exercise training, promotion of healthy behaviors (eg, smoking cessation, regular exercise, healthy nutrition, proper medication use, adherence to prescribed medications, disease self-management) and psychological support (eg, improving self-efficacy, providing coping strategies for chronic illness).

Pulmonary Rehabilitation Effective Date:

09/28/2023

Revision Date:

09/28/2023

Review Date:

09/28/2023

Policy Number:

HUM-0338-017

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

The goals of pulmonary rehab include:

• Minimizing symptom burden
• Maximizing exercise performance
• Promoting autonomy
• Increasing participation in everyday activities
• Enhancing health-related quality of life
• Effecting long-term health-enhancing behavior change.

Coverage Determination

Humana members may be eligible under the Plan for outpatient pulmonary rehabilitation for the following indications:

• Endobronchial valves (EBV) surgery, pre- and postop; OR
• Lung transplant, pre- and postop; OR
• Lung volume reduction surgery, pre- and postop

Humana members may be eligible under the Plan for outpatient pulmonary rehabilitation when the following criteria are met:

• Diagnosed with a chronic pulmonary disease*, with limited physical activity, frequent exacerbations and FEV1 (forced expiratory volume in one second) less than 50% predicted; OR
• Diagnosed with a restrictive pulmonary disease due to a neuromuscular disorder affecting lung function (eg, amyotrophic lateral sclerosis [ALS], Guillain-Barre syndrome)

AND ALL of the following:

• Absence of contraindications; AND
• Decreased exercise tolerance or a decline in an individual’s ability to perform activities of daily living (ADLs); AND
• Dyspnea at rest or with exertion; AND
• Individual must be nicotine-free for 6 weeks; AND
• Individuals who have been nicotine users must provide documentation of nicotine cessation, as evidenced by negative lab test report for cotinine; AND

• Physically able, motivated and willing to participate in the pulmonary rehab program and be a candidate for self-care post-program; AND
• Symptoms persist despite appropriate conventional care for the specific diagnosis; AND
• Individuals may be eligible for one series per lifetime consisting of 1 to 2 hour sessions 3 times a week for a maximum of 6 weeks (36 session limit); AND
• Commercial Plan members: requests for the following require review by a medical director:
  • Exceptions for repeat pulmonary rehabilitation in those individuals undergoing EBV surgery, lung transplant or lung volume reduction surgery; OR
  • Requests for greater than 36 therapy sessions

Examples of chronic pulmonary diseases include, but may not be limited to:

• Asthma
• Bronchiectasis
• COPD (including chronic bronchitis, emphysema)
• Cystic fibrosis
• Interstitial lung disease (eg, post-adult respiratory distress syndrome, pulmonary fibrosis)

Note: The criteria for outpatient pulmonary rehabilitation are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for outpatient pulmonary rehabilitation for any indications other than those listed above, including the following:

• Group pulmonary rehabilitation (as this is not one-on-one and customized to the specific individual’s needs); OR
• Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring

These are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Potential contraindications to outpatient pulmonary rehabilitation include, but may not be limited to, the following:

• Acute cor pulmonale
• Metastatic cancer
• Neurologic impairment that interferes with memory and compliance
• Renal failure
• Severe arthritis
• Severe cognitive deficit
• Severe pulmonary hypertension
• Significant hepatic dysfunction
• Uncontrolled cardiac disease^1,2

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about pulmonary rehabilitation may be found from the following websites:

• American Association for Respiratory Care
• American College of Chest Physicians
• American Lung Association
• National Library of Medicine

Medical Alternatives

Alternatives to pulmonary rehabilitation include, but may not be limited to, the following:

• There is no cure for COPD, but symptoms may be reduced by other treatments (eg, chest percussion, oxygen, nebulizer treatments).

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.