Coverage Policy Manual
Policy #: 1997151
Category: Rehabilitation
Initiated: September 1997
Last Review: May 2018
  Cardiac Rehabilitation

Description:
Cardiac Rehabilitation is a program of multidisciplinary intervention designed to assist clinically suitable cardiac patients to attain and maintain their optimal level of functioning.  As defined by the United States Public Health Service:  'Cardiac rehabilitation services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling.  These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial vocational status of selected patients.'
 
The goal of such programs is to reduce the morbidity and mortality associated with cardiovascular disease.  The scientific literature documents that some of the benefits of participation in a cardiac rehabilitation program include improvement in exercise tolerance, blood lipid levels, and psychosocial well-being, as well as a reduction in cigarette smoking and stress.  Meta-analysis of data from randomized controlled studies indicates a reduction in mortality in patients participating in cardiac rehabilitation following myocardial infarction.
 
Under clinically controlled conditions the cardiac patient improves physical endurance and stamina through participation in an individualized exercise regimen.  Behavioral interactions, an integral component of a comprehensive rehabilitation program, are designed to educate and motivate the patients to adopt long-term lifestyle changes that help to reduce cardiovascular risk factors amenable to patient control, e.g., diet, smoking, stress management.
 
Coding
Outpatient Cardiac Rehab services should be reported using CPT codes 93797 or 93798. The HCPCS codes G0422 and G0423 describe a frequency greater than the policy allows and therefore, will not be covered for cardiac rehabilitation services.
 

Policy/
Coverage:
Effective November 2014
 
For some contracts, this service is a contract specific benefit. Additional restrictions may apply to members with contracts with limitations or exclusions for cardiac rehabilitation therapy.
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Cardiac Rehabilitation Programs meet primary coverage criteria for effectiveness and are covered when:
    • The program is provided in either the outpatient department of a hospital or in a physician directed clinic;
    • The physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician;
    • The facility has available for immediate use all the necessary cardio-pulmonary emergency diagnostic and therapeutic life saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator;
    • The program is conducted in an area set aside for the exclusive use of the program while it is in session;
    • The program is staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease. Services of non-physician personnel must be furnished under the direct supervision of a physician. Direct supervision means that a physician must be in the exercise program area. It does not mean the physician must physically be present in the exercise room itself but must be immediately available and accessible for an emergency at all times;
    • The non physician personnel are employees of the physician, hospital, or clinic conducting the program and their services are incident to a physician's professional services.
 
Cardiac Rehabilitation Programs meet primary coverage criteria for effectiveness and are eligible for coverage for patients who:
    • Have a clear clinical need for this type of program and are referred by their physician for participation in the program; and
    • Have one of the following in the 12 months prior to the initiation of the Cardiac Rehab program:
        • Stable angina pectoris;
        • History of acute myocardial infarction;
        • Coronary artery bypass, PTCA, or other types of percutaneous therapeutic coronary artery intervention, such as atherectomy, stent placement, etc.;
        • Heart transplant or heart/lung transplant;
        • Repair or replacement of heart valve;
        • Class III or IV CHF;
        • Sustained ventricular tachycardia or fibrillation; or
        • Survivor following cardiac arrest.
 
Cardiac Rehabilitation programs meet primary coverage criteria for effectiveness and are eligible for coverage when rendered at a frequency of three sessions per week up to a duration of twelve weeks (36 sessions).
 
Outpatient Cardiac Rehab services should be reported using CPT codes 93797 or 93798.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Psychotherapy/Psychological Testing is not covered as a routine part of the evaluation or treatment of a candidate for a Cardiac Rehabilitation Program.
 
*Note: These services may be covered if the patient has a diagnosed mental, psychoneurotic, or personality disorder and/or exhibits symptoms of a severity that warrant evaluation and/or therapy.
 
Physical and Occupational Therapy services are not covered as a routine part of a Cardiac Rehabilitation Program.
 
*Note: These services may be covered if the patient has a non-cardiac condition for which physical and/or occupational therapy are considered medically necessary.
 
Patient Education is not covered as a separately identifiable service when rendered as part of a Cardiac Rehabilitation Program.
 
Room and Board furnished to patients or family members by some free-standing facilities is not covered.
 
Other uses of cardiac rehabilitation does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without primary coverage criteria, other uses of cardiac rehabilitation is considered investigational. Investigational services are an exclusion in the member certificate of coverage.
 
HCPCS codes G0422 and G0423 describe a frequency greater than the policy allows.  These services do not meet primary coverage criteria and are not covered. For members with contracts without primary coverage criteria, services described by G0422 and G0423 are considered not medically necessary. Services that are not medically necessary are specific contract exclusions in most member benefit certificates.
 
Effective Prior to November 2014
 
Cardiac Rehabilitation Programs meet primary coverage criteria for effectiveness and are covered when:
    • The program is provided in either the outpatient department of a hospital or in a physician directed clinic;
    • The physician is on the premises available to perform medical duties at all times the facility is open and each patient is under the care of a hospital or clinic physician;
    • The facility has available for immediate use all the necessary cardio-pulmonary emergency diagnostic and therapeutic life saving equipment accepted by the medical community as medically necessary, e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator;
    • The program is conducted in an area set aside for the exclusive use of the program while it is in session;
    • The program is staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life support techniques and in exercise therapy for coronary disease.  Services of non-physician personnel must be furnished under the direct supervision of a physician.  Direct supervision means that a physician must be in the exercise program area.  It does not mean the physician must physically be present in the exercise room itself but must be immediately available and accessible for an emergency at all times;
    • The non physician personnel are employees of the physician, hospital, or clinic conducting the program and their services are incident to a physician's professional services.
 
Psychotherapy/Psychological Testing is not covered as a routine part of the evaluation or treatment of a candidate for a Cardiac Rehabilitation Program.  These services may be covered if the patient has a diagnosed mental, psychoneurotic, or personality disorder and/or exhibits symptoms of a severity that warrant evaluation and/or therapy.
 
Physical and Occupational Therapy services are not covered as a routine part of a Cardiac Rehabilitation Program. These services may be covered if the patient has a non-cardiac condition for which physical and/or occupational therapy are considered medically necessary.
 
Patient Education is not covered as a separately identifiable service when rendered as part of a Cardiac Rehabilitation Program.
 
Room and Board furnished to patients or family members by some free-standing facilities is not covered.
 
Cardiac Rehabilitation Programs meet primary coverage criteria for effectiveness and are eligible for coverage for patients who:
    • Have a clear clinical need for this type of program and are referred by their physician for participation in the program; and
    • Have one of the following in the 12 months prior to the initiation of the Cardiac Rehab program:
      • Stable angina pectoris;
      • History of acute myocardial infarction;
      • Coronary artery bypass, PTCA, or other types of percutaneous therapeutic coronary artery intervention, such as atherectomy,  stent placement, etc.;
      • Heart transplant or heart/lung transplant;
      • Repair or replacement of heart valve;
      • Class III or IV CHF;
      • Sustained ventricular tachycardia or fibrillation; or
      • Survivor following cardiac arrest.
 
Cardiac Rehabilitation programs meet primary coverage criteria for effectiveness and are eligible for coverage when rendered at a frequency of three sessions per week up to a duration of twelve weeks (36 sessions).
 
Other uses of cardiac rehabilitation is not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without primary coverage criteria, other uses of cardiac rehabilitation is considered investigational.  Investigational services are an exclusion in the member certificate of coverage.

Rationale:
This policy was was based on a clinical practice guideline issued by the U.S. Department of Health and Human Services (HHS) in 1995, which recommended cardiac rehabilitation services for patients with coronary heart disease (CHD) and with heart failure, including those awaiting or following cardiac transplantation.
 
2011 Update
A literature search through June 2011 did not identify any literature that would prompt a change in the coverage statement.
 
A 2010 Cochrane review by Davies and colleagues focused on exercise-based rehabilitation for adults with systolic heart failure (Davies, 2010). The authors searched for RCTs of exercise-based rehabilitation (alone or as part of comprehensive cardiac rehabilitation programs) in which patients were followed for at least 6 months. A total of 19 trials with 3,647 heart failure patients were identified; one large trial, HF-ACTION, contributed 2,331 (60%) patients. Overall quality of the studies was judged to be poor; for example, only 3 studies adequately described their randomization process, and only 3 studies had blinded outcome assessment. A pooled analysis of the 13 studies reporting all-cause mortality with up to 12 months’ follow-up, did not find a statistically significant difference in mortality between groups (RR: 1.02, 95% CI: 0.70 to 1.51, p=0.90). Similarly, there was not a significant difference between groups in all-cause mortality in a pooled analysis of the 4 studies reporting more than 12 months’ follow-up (RR: 0.88, 95% CI: 0.73 to 1.07). No significant between-group differences were found for the other primary outcome variable, hospital admissions. For example, when findings from 5 studies reporting hospital admissions up to 12 months were pooled, the relative risk was 0.79 (95% CI: 0.58 to 1.07). The vast majority of the studies included in the Cochrane review, including the HF-ACTION trial, were exercise-only interventions; thus, conclusions cannot be drawn from this review regarding the impact of comprehensive cardiac rehabilitation programs on mortality or hospital admissions in patients with heart failure. The Cochrane review did not require that studies only include patients with compensated heart failure.
 
Also in 2010, the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation published a position paper on cardiac rehabilitation. Recommendations were based on a review of national guidelines from the U.S. and Europe.  They stated that core components of cardiac rehabilitation are patient assessment, physical activity counseling, exercise training, diet/nutritional counseling, weight-control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. The recommended criteria for adequate exercise training are:
    • Mode: Continuous endurance e.g., walking, jogging, cycling, swimming, etc.
    • Duration: At least 20-30 minutes (preferably 45-60 minutes)
    • Frequency: Most days (at least 3 days per week and preferably 6-7 days per week)
    • Intensity: 50-80% of peak oxygen consumption or of peak heart rate or 40-60% of heart rate reserve.
 
The position paper did not address repeat participation in cardiac rehabilitation programs. The coverage statement has not been changed.
 
2012 Update
A search of the MEDLINE database was conducted through September 2012.  There was no new information identified that would prompt a change in the coverage statement.
 
2013 Update
A search of the MEDLINE database through 2013 did not reveal any new literature that would prompt a change in the coverage statement.
 
In 2012, the American College of Physicians, American College of Cardiology Foundation, American Heart Association/American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association and Society of Thoracic Surgeons published a joint guideline on management of stable ischemic heart disease (Qaseem, 2012). The guideline included the following statement on cardiac rehabilitation: Medically supervised exercise programs, i.e., cardiac rehabilitation and physician-directed home-based programs, are recommended for at-risk patients at first diagnosis of stable ischemic heart disease. The current coverage statement is consistent with this guideline for physician directed out-patient cardiac rehabilitation.
 
2014 Update
A literature search conducted through June 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A concern raised by the negative findings in the RAMIT trial is the majority of the RCTs evaluating cardiac rehabilitation was conducted in an earlier era of heart disease management, and may not be relevant to current care. Although no new RCT evidence was identified, several newer nonrandomized studies have been published since the RAMIT trial that corroborate prior RCT evidence about the benefit of cardiac rehabilitation after myocardial infarction. Two examples of such studies are provided here.
 
In 2013, Pack et al assessed the association between cardiac rehabilitation attendance and outcomes among 846 patients in a single Minnesota county who underwent coronary artery bypass grafting (CABG) from 1996 to 2007 (Pack, 2013). After propensity score adjustment, attending cardiac rehabilitation was associated with a reduced risk of 10-year mortality (hazard ratio 0.54, 95% CI 0.01 to 0.74, P<0.001).
 
In a longitudinal observational study, Coll-Fernandez et al compared mortality and subsequent ischemic event rates after acute MI between patients who underwent cardiac rehabilitation (n=521) and those who did not (n=522).  In multivariate analysis, patients who underwent cardiac rehabilitation had lower mortality than those who did not (adjusted hazard ratio 0.08, 95% CI 0.01 to 0.63, P=0.016).
 
Although these nonrandomized studies published since the RAMIT trial are limited by the potential for residual confounding by unobserved variables even after propensity-score adjustment or multivariable adjustment, they provide some additional evidence supporting the use of cardiac rehabilitation in the current era of cardiac care.
 
Ongoing Clinical Trials
A search of the online database ClinicalTrials.gov on 5/15/14 using the term “cardiac rehabilitation” as the intervention identified the following randomized studies that are currently enrolling patients:
 
Enhancing Standard Cardiac Rehabilitation With Stress Management Training in Patients With Heart Disease (ENHANCE) (NCT00981253) – This is a randomized, open-label trial designed to evaluate whether cardiac rehabilitation incorporating exercise and stress management is more effective than standard cardiac rehabilitation at improving cardiac biomarkers among patients with a diagnosis of coronary heart disease who are eligible for cardiac rehabilitation. Enrollment is planned for 150 subjects; the planned study completion date is May 2014.
 
Multi-Disciplinary Rehabilitation Program in Recently Hospitalized Patients With Preserved Ejection Fraction Heart Failure (NCT01914315) – This is a randomized, single-blinded (outcomes assessor-blinded) study to evaluate whether comprehensive cardiac rehabilitation is superior to standard care for patients with heart failure with preserved systolic function who are discharged after an acute heart failure event. Enrollment is planned for 1100 subjects; the planned study completion date is January 2016.
 
OPTImal CArdiac REhabilitation (OPTICARE) Following Acute Coronary Syndromes: A Randomized, Controlled Trial to Investigate the Benefits of an Expanded Educational and Behavioural Intervention Program (NCT01395095) – This is a randomized, open-label trial designed to compare two extended cardiac rehabilitation programs to a standard cardiac rehabilitation program among patients with acute coronary syndrome treated with primary or elective percutaneous coronary intervention or coronary surgery. Enrollment is planned for 1200 subjects; the planned study completion date is March 2016.
 
Effects of Homebased Training With Telemonitoring Guidance in Low to Moderate Risk Patients Entering Cardiac Rehabilitation (NCT01732419) – This is a randomized, open label trial to compare home-based cardiac rehabilitation to center-based cardiac rehabilitation among patients with acute coronary syndrome or a cardiac revascularization procedure. Enrollment is planned for 90 subjects; the planned study completion date is October 2014.
 
Efficacy of Physical Exercise in Cardiac Rehabilitation (NCT01617850) – This is a randomized, single-blinded trial to compare an “optimized” (higher-intensity” exercise program to a conventional program for improvement in exercise-related parameters among patients with angina pectoris, acute myocardial infarction, and chronic heart failure. Enrollment is planned for 70 subjects; the study completion date was listed as December 13. No results have been published.
 
Cardiopulmonary Rehabilitation for Adolescents and Adults With Congenital Heart Disease (NCT01822769) – This is a randomized, single-blinded trial to compare a formal 12-week outpatient cardiac rehabilitation program to standard care for adults and children with congenital heart disease and impaired aerobic capacity. Enrollment is planned for 60 subjects; the planned study completion date is December 2014.
 
Practice Guidelines and Position Statements
2013, the American College of Cardiology Foundation and the American Heart Association published updated guidelines on the management of heart failure (Yancy, 2013). These guidelines include the following Class IIA recommendation related to cardiac rehabilitation (Level of Evidence: B): Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL [health-related quality of life], and mortality.
 
 
2015 Update
A literature search conducted through October 2015 did not reveal any new information that would prompt a change in the coverage statement.
 
2018 Update
A literature search conducted through April 2018 did not reveal any new information that would prompt a change in the coverage statement.
    

CPT/HCPCS:
93797Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
93798Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)
G0422Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
G0423Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session

References: Clinical Practice Guidelines, Number 17, Cardiac Rehabilitation. AHCPR Pub #96-0672 1995.

Davies EJ, Moxham T, Rees K et al.(2010) Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev 2010: (4):CD003331.

European Association of Cardiovascular Prevention and Rehabilitation Committee for Science Guidelines; Corra U, Piepoli MF, Carre F et al.(2010) Secondary prevention through cardiac rehabilitation: physical activity counseling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the EACPR. Eur Heart J 2010: 31(16):1967-76.

Pack QR, Goel K, Lahr BD et al.(2013) Participation in cardiac rehabilitation and survival after coronary artery bypass graft surgery: a community-based study. Circulation 2013; 128(6):590-7.

Qaseem A, Fihn SD, Dallas P et al.(2012) Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012; 157(10):735-43.

Yancy CW, Jessup M, Bozkurt B et al.(2013) 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.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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