Humana Commercial Clinical Policy

Humana Cardiac Rehabilitation Form


Effective Date

11/02/2023

Last Reviewed

NA

Original Document

  Reference



Description

Cardiac rehabilitation is designed to help an individual with conditions such as heart or vascular disease return to a healthier and a more productive life. This includes an individual who has had a heart attack, open heart surgery, stable angina, vascular disease or other cardiac related health problems.

Cardiac rehabilitation following a cardiac event is divided into four phases:

  • Phase I cardiac rehabilitation begins in the hospital (inpatient) after experiencing a heart attack or other major cardiac event. During this phase, the individual receives education and nutritional counseling to prepare them for discharge.
  • Phase II outpatient cardiac rehabilitation begins after leaving the hospital. It is a comprehensive program including medical evaluation, prescribed exercise, cardiac risk factor modification, education and counseling. Phase II refers to medically supervised programs that typically begin one to three weeks after discharge and provide appropriate electrocardiographic monitoring.
  • Phase III cardiac rehabilitation continues the exercise program and healthy activities learned in phase II. It is usually performed at home or in a fitness center with supervision to facilitate risk factor modification and promote a healthy lifestyle. (Refer to Coverage Limitations section)
  • Phase IV cardiac rehabilitation is based on an indefinite exercise maintenance program. These programs encourage a commitment to regular exercise and healthy habits for risk factor modification to establish lifelong cardiovascular fitness. Some programs combine phases III and IV. (Refer to Coverage Limitations section)

Intensive Cardiac Rehabilitation (ICR) programs

include exercise, extensive nutrition education, stress management and group support (eg, Benson-Henry Institute Cardiac Wellness Program, Ornish Program for Reversing Heart Disease, Pritikin Program). (Refer to Coverage Limitations section)

For information regarding mobile health (mHealth) applications or mobile medical applications (MMAs), please refer to Digital Therapeutics Medical Coverage Policy.
For information regarding supervised structured exercise therapy (SET) or rehabilitation, please refer to Peripheral Artery Disease of the Lower Extremities Angiography, Screening and Exercise Rehabilitation Medical Coverage Policy.

Coverage Determination

Any state mandates for outpatient phase II cardiac rehabilitation take precedence over this medical coverage policy.

Refer to specific certificate language regarding cardiac rehabilitation. Most certificates limit the duration or number of visits.

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

  • Absence of contraindications; AND

Cardiac Rehabilitation Effective Date: 11/02/2023 Revision Date: 11/02/2023 Review Date: 11/02/2023 Policy Number: HUM-0334-016

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.

  • Continuous electrocardiogram (ECG) monitoring performed by a physician or other qualified health care professional; AND
  • May receive up to 36 sessions (generally 2 to 3 sessions per week for 12 weeks); AND
  • Prescribed by a licensed health care practitioner within the preceding 12 months after ANY of the following:
    1. Acute myocardial infarction (AMI); OR
    2. Coronary bypass surgery (also referred to as coronary artery bypass surgery or CABG); OR
    3. Heart or heart-lung transplant; OR
    4. Heart valve repair or replacement; OR
    5. Percutaneous coronary intervention (eg, angioplasty, atherectomy, stenting); OR
    6. Placement of a ventricular assist device (VAD); OR
    7. Stable angina pectoris that is refractory to medical management and interfering with activities of daily living; OR
    8. Stable, chronic heart failure (HF) with left ventricular ejection fraction (LVEF) of 35 percent or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks (stable is defined as no recent [less than or equal to 6 weeks] or planned [less than or equal to 6 months] major cardiovascular hospitalizations or procedures)

Note: The criteria for phase II cardiac 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.

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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.

Coverage Limitations

Humana members may NOT be eligible under the Plan for outpatient phase II cardiac rehabilitation for any indications other than those listed above, including physician supervision of non-electrocardiogram (ECG) monitored cardiac rehabilitation. All other indications 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.

  • Active pericarditis or myocarditis; OR
  • Acute systemic illness or fever; OR
  • Acute thrombophlebitis; OR
  • Decompensated heart failure; OR
  • Orthostatic blood pressure (BP) drop of greater than 20 mmHg with symptoms; OR
  • Other metabolic conditions, such as acute hyperkalemia, hypokalemia, hypovolemia or thyroiditis (until adequately treated); OR
  • Recent embolism; OR
  • Severe orthopedic conditions that would prohibit exercise; OR
  • Significant aortic stenosis (aortic valve area less than 1.0 cm2); OR
  • Third degree atrioventricular (AV) block without pacemaker; OR
  • Uncontrolled atrial or ventricular arrhythmias; OR
  • Uncontrolled diabetes mellitus; OR

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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.

  • Uncontrolled hypertension – resting systolic blood pressure (SBP) greater than 180 mmHG and/or resting diastolic BP (DBP) greater than 110 mmHG; OR
  • Uncontrolled sinus tachycardia (greater than 120 beats/min); OR
  • Unstable angina

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.

Humana members may NOT be eligible under the plan for Phase III, Phase IV cardiac rehabilitation and ICR as these programs are considered educational and training in nature. Any cardiac rehabilitation services that are considered primarily educational or training in nature are generally NOT covered under most Humana benefit Plans. For those Plans that do not specifically exclude education and training, 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.

Additional information about cardiovascular (heart) disease may be found from the following websites:

Background
  • American Heart Association • National Library of Medicine
Medical Alternatives

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.

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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.

Provider Claims Codes

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.

References

1. American College of Cardiology (ACC). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. https://www.acc.org.

Published January 29, 2013. Accessed October 16, 2023.

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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.

  • American College of Cardiology (ACC). 2014 AHA/ACC guideline for the management of patients with non-ST elevation acute coronary syndromes. https://www.acc.org. Published December 23, 2014. Accessed October 16, 2023.
  • American College of Cardiology (ACC). 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. https://www.acc.org. Published January 18, 2022. Accessed October 16, 2023.
  • American College of Cardiology (ACC). 2022 AHA/ACC/HFSA guideline for the management of heart failure. https://www.acc.org. Published May 3, 2022. Accessed October 16, 2023.
  • American College of Cardiology (ACC). 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease. https://www.acc.org. Published August 29, 2023. Accessed October 16, 2023.
  • American College of Cardiology (ACC). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. https://www.acc.org. Published November 29, 2011. Accessed October 16, 2023.
  • American Heart Association (AHA). AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services. https://www.acc.org. Published September 28, 2010. Accessed October 16, 2023.
  • American Heart Association (AHA). AHA Presidential Advisory. Referral, enrollment and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond. https://www.heart.org. Published December 1, 2011. Accessed October 16, 2023.
  • American Heart Association (AHA). AHA Scientific Statement. Cardiac rehabilitation and secondary prevention of coronary heart disease. https://www.heart.org. Published January 25, 2005. Accessed October 16, 2023.

Cardiac Rehabilitation Effective Date: 11/02/2023 Revision Date: 11/02/2023 Review Date: 11/02/2023 Policy Number: HUM-0334-016 Page: 8 of 11

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.

  • Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Covered medical and other health services. https://www.cms.gov. Published January 1, 2022. Accessed October 9, 2023.
  • Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Billing requirements for special services. https://www.cms.gov. Published January 1, 2022. Accessed October 9, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Benson-Henry Institute Cardiac Wellness Program (20.31.3). https://www.cms.gov. Published May 6, 2014. Accessed October 13, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Cardiac rehabilitation programs for chronic heart failure (20.10.1). https://www.cms.gov. Published February 18, 2014. Accessed October 13, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Intensive cardiac rehabilitation (ICR) programs (20.31). https://www.cms.gov. Published August 12, 2010. Accessed October 13, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Ornish Program for reversing heart disease (20.31.2). https://www.cms.gov. Published August 12, 2010. Accessed October 13, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). The Pritikin Program (20.31.1). https://www.cms.gov. Published August 12, 2010. Accessed October 13, 2023.
  • ECRI Institute. Hotline Response (ARCHIVED). Intensive cardiac rehabilitation programs for reducing cardiovascular disease risk factors. https://www.ecri.org. Published July 28, 2015. Accessed October 3, 2023.
  • H ayes, Inc. Medical Technology Directory (ARC H IVED). Cardiac rehabilitation programs. https://evidence.hayesinc.com. Published March 26, 2003. Updated April 15, 2008. Accessed October 3, 2023.

Cardiac Rehabilitation Effective Date: 11/02/2023 Revision Date: 11/02/2023 Review Date: 11/02/2023 Policy Number: HUM-0334-016 Page: 9 of 11

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.

  • H ayes, Inc. Medical Technology Directory (ARCH IVED). Comparative effectiveness review of intensive cardiac rehabilitation programs for coronary artery disease. https://evidence.hayesinc.com. Published February 22, 2018. Updated January 14, 2022. Accessed October 3, 2023.
  • International Society of Heart and Lung Transplantation (ISHLT). The International Society of Heart and Lung Transplantation guidelines for the care of heart transplant recipients. https://www.ishlt.org. Published August 2010. Accessed October 16, 2023.
  • MCG Health. Cardiac rehabilitation. 27th edition. https://www.mcg.com. Accessed August 28, 2023.
  • UpToDate, Inc. Cardiac rehabilitation in older adults. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • UpToDate, Inc. Cardiac rehabilitation in patients with heart failure. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.

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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.

  • UpToDate, Inc. Cardiac rehabilitation: indications, efficacy and safety in patients with coronary heart disease. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • UpToDate, Inc. Cardiac rehabilitation programs. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • UpToDate, Inc. Heart transplant in adults: exercise-based rehabilitation for transplant recipients. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • UpToDate, Inc. Management of long-term mechanical circulatory support devices. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • UpToDate, Inc. Overview of the management of heart failure with reduced ejection fraction in adults. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • UpToDate, Inc. Overview of the nonacute management of ST-elevation myocardial infarction. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • UpToDate, Inc. Overview of the nonacute management of unstable angina and non-ST elevation myocardial infarction. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • UpToDate, Inc. Physical therapy and other rehabilitation issues in the palliative care setting. https://www.uptodate.com. Updated September 2023. Accessed October 3, 2023.
  • US Government Publishing Office. Electronic code of federal regulations: part 410 - § 410.49 Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage. https://www.ecfr.gov. Published November 25, 2009.

Updated November 19, 2021. Accessed October 13, 2023.

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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.

Appendix A

New York Heart Association (NYHA) Functional Classification System
  • Classification
    • No limitations on physical activity; ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath) or anginal pain.
  • Class II (mild)
    • Slight limitation of physical activity; comfortable at rest; ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain.
  • Class Ill (moderate)
    • Marked limitation of physical activity; comfortable at rest; less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain.
  • Class IV (severe)
    • Inability to carry on any physical activity without discomfort; symptoms of cardiac insufficiency may be present even at rest. If any physical activity is undertaken,
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