HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
G-17-036
Topic:
Outpatient Pulmonary Rehabilitation
Section:
Miscellaneous
Effective Date:
May 27, 2024
Issued Date:
May 27, 2024
Last Revision Date:
April 2024
Annual Review:
April 2024
 
 

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

Comprehensive outpatient PR programs may include: team assessment, individual training, psychosocial intervention, exercise training, and follow-up. Individuals should have the ability to perform the exercise training and have a high level of motivation to participate in and complete the program.

Individuals for PR should be medically stable and not limited by another serious or unstable medical condition. Contraindications to PR include but are not limited to:

  • Severe psychiatric disturbance (i.e., dementia, organic brain syndrome); or
  • Significant or unstable medical conditions (i.e., heart failure, acute cor pulmonale, substance abuse, significant liver dysfunction, metastatic cancer, or disabling stroke); or
  • Currently smoking. 

The focus of therapy is to educate the individual and establish a program of adaptive changes to a chronic medical illness. The optimal outcome is achieved when the patient continues these adaptive changes on an independent basis after discharge from the program.

Policy Position

A single course of PR in the outpatient ambulatory care setting may be considered medically necessary for ANY of the following indications:

  • Treatment of chronic pulmonary disease for individuals with moderate to severe disease (see Table) who are experiencing disabling symptoms and significantly diminished QOL despite optimal medical management; or 
  • Pre-operative conditioning component for those considered appropriate candidates for lung volume reduction surgery or for lung transplantation; or
  • Following lung transplantation; or
  • Post Covid-19 condition.

Outpatient PR not meeting the criteria as indicated in this policy is considered not medically necessary.

Table

Classification of Severity of Airflow Limitation in COPD a,b

GOLD 1

Mild

FEV1 greater than or equal to 80% predicted

GOLD 2

Moderate

50% less than or equal to FEV1 less than 80% predicted

 

GOLD 3

Severe

30% less than or equal to FEV1 less than 50% predicted

GOLD 4

Very Severe

 FEV1 less than 30% predicted
a Based on post-bronchodilator FEV1

b In patients with FEV1/FVC  less than 0.70

94625

94626

94640

94664

94667

94668

94760

94761

97001

97002

97110

97116

97150

97161

97162

97163

97164

97530

97750

99205

99211

99212

99213

99214

99215

G0237

G0238

G0239

 

 

        

 


Comprehensive outpatient PR programs may include: team assessment, individual training, psychosocial intervention, exercise training, and follow-up. An initial PR program of up to 36 sessions may be considered medically necessary.

The PR program may include the following: 

  • Team assessment:
    • May include input from:
      • Physician; and
      • Respiratory care practitioner; and
      • Nurse; and
      • Psychologist; and
      • Others as needed.
  •  Individual training:
    •  May include:
      • Breathing training; and
      • Bronchial hygiene; and
      • Medications; and
      • Proper Nutrition.
  • Psychosocial intervention:
    • May address:
      • Support system; and
      • Dependency issues.
  • Exercise training:
    • Includes strengthening and conditioning and may utilize the following:
      • Stair climbing; or
      • Inspiratory muscle training; or
      • Treadmill walking; or
      • Cycle training (with or without ergometer); or
      • Supported and unsupported arm exercise training.

Note: 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.

  • Follow up:
    • May include supervised home exercise conditioning.

An additional 36 sessions may be considered medically necessary upon review for a total of 72 lifetime sessions.

Quantity level limits (QLL) that exceeds the frequency guidelines listed on the policy are considered not medically necessary.

Outpatient PR not meeting the criteria as indicated in this policy is considered not medically necessary.

94625

94626

94640

94664

94667

94668

94760

94761

97001

97002

97110

97116

97150

97161

97162

97163

97164

97530

97750

99205

99211

99212

99213

99214

99215

G0237

G0238

G0239

 

 

 

 

 

 

 


Related Policies

Refer to Medical Policy S-123, Lung and Lobar Lung Transplant, for additional information.

Refer to Medical Policy S-125, Heart/Lung Transplant, for additional information.

Refer to Reimbursement Policy RP-041, Services Not Separately Reimbursed, for additional information.


Professional Statements and Societal Positions Guidelines

Global Initiative for Chronic Obstructive Lung Disease- 2023

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) updates their guidelines annually on the diagnosis, management, and prevention of COPD. In their 2023 guidance, GOLD notes that:

"Pulmonary rehabilitation should be considered as part of integrated patient management... Optimum benefits are achieved from programs lasting 6 to 8 weeks. Available evidence indicates that there are no additional benefits from extending pulmonary rehabilitation to 12 weeks. Supervised exercise training at least twice weekly is recommended, and this can include any regimen from endurance training, interval training, resistance/strength training; upper and lower limbs ideally should be included as well as walking exercise; flexibility, inspiratory muscle training and neuromuscular electrical stimulation can also be incorporated. In all cases the rehabilitation intervention (content, scope, frequency, and intensity) should be individualized to maximize personal functional gains."

The benefits to patients with COPD from pulmonary rehabilitation cited in the guidelines are listed in the Table below.

Table. Benefits of Pulmonary Rehabilitation in Patients with COPD (GOLD guidelines)

Pulmonary Rehabilitation Benefit

LOE

Pulmonary rehabilitation improves dyspnea, health status, and exercise tolerance in stable patients.

A

Pulmonary rehabilitation reduces hospitalization among patients who have had a recent exacerbation (≤4 weeks from prior hospitalization).

B

Pulmonary rehabilitation leads to a reduction in symptoms of anxiety and depression.

A


 

E84.0

J41.0

J41.1

J41.8

J42

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.89

J44.9

J47.0

J47.1

J47.9

J60

J61

J62.0

J62.8

J63.0

J63.1

J63.2

J63.3

J63.4

J63.5

J63.6

J64

J65

J66.0

J66.1

J66.2

J66.8

J84.10

J84.170

J84.178

J84.89

J95.1

J95.2

J95.3

J95.821

J95.822

J96.00

J96.20

J96.21

J96.22

J98.2

J98.3

Z48.24

Z48.280

Z86.16

Z90.2

Z94.2

Z94.3

U09.9


Place of Service: Outpatient

Outpatient Pulmonary Rehabilitation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.