HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
V-1-025
Topic:
Cardiac Rehabilitation Programs, Phase II Outpatient
Section:
Visits
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
September 2021
 
 

Cardiac rehabilitation program, phase II refers to comprehensive medically supervised programs in the outpatient setting that aim to improve the function of individuals with heart disease and prevent future cardiac events.

Policy Position

Cardiac rehabilitation programs, Phase II Outpatient may be considered medically necessary when individually prescribed by a physician and the following criteria are met:

  • Initiated within 12 months of ANY of the following:
    • Acute myocardial infarction (MI) (heart attack); or
    • Coronary artery bypass graft (CABG) surgery; or
    • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
    • Heart valve surgery; or
    • Heart or heart-lung transplantation; or
    • Current stable angina pectoris; or
    • Compensated heart failure; or
    • Peripheral Aterery Disease; or
    • Coronary artery disease (CAD) associated with chronic; stable angina pectoris that has failed to respond adequately to pharmacotherapy and is interfering with the ability to perform age-related activities of daily living and/or impairing functional abilities; and
  • The individual does not have an absolute contraindication to cardiac rehabilitation (examples include: unstable angina, overt cardiac failure, dangerous arrhythmias, dissecting aneurysm, myocarditis, acute pericarditis, severe obstruction of the left ventricular outflow tract, severe hypertension, exertional hypotension or syncope, uncontrolled diabetes mellitus, severe orthopedic limitations, and recent systemic or pulmonary embolus).

Following the initial evaluation, services provided in conjunction with a phase II outpatient cardiac rehab program may be considered medically necessary for up to 36 sessions, three (3) sessions per week, for a 12-week period. The need for supervised exercise sessions can be determined by the individual’s risk stratification as follows:

  • Low Risk: six (6)-18 exercise sessions
  • Moderate Risk: 12-24 exercise sessions
  • High Risk: 18-36 exercise sessions

A routine cardiac rehabilitation session usually consists of an exercise training session lasting 20-60 minutes and at least ONE of the following services:

  • Continuous ECG/EKG monitoring during exercise; or
  • EKG rhythm strip with interpretation and physician's revision of the exercise program; and/or
  • Limited physician follow-up to adjust medication or other treatment(s) related to the program.

Cardiac rehabilitation exercise programs beyond the initial 12-week/36 session will require individual medical review. If documentation substantiates that additional sessions are medically necessary to reach a realistic and achievable increase in work capacity, the number of services may be extended, but not exceed a maximum of 24 weeks or 72 sessions.

Phase II cardiac rehabilitation services that do not meet the medical necessity criteria and frequency guidelines outlined on this policy will be denied as not medically necessary.

Maintenance exercise programs are noncovered once the individual has completed the formal prescribed program at a freestanding clinic or facility.

Generally, psychotherapy and psychological testing are not considered medically necessary for all cardiac rehabilitation participants. However, if a participant has been diagnosed with a mental, psychoneurotic or personality disorder, psychotherapy performed by a psychiatrist or a psychologist it may be considered medically necessary.  In addition, psychological diagnostic testing of a cardiac rehabilitation participant who exhibits symptoms of mental illness or mental problems (e.g., anxiety disorder associated with the cardiac disease) may be considered medically necessary.

Physical and/or occupational therapies are considered not medically necessary in conjunction with cardiac rehabilitation services unless performed for an unrelated diagnosis (e.g., a participant who is recuperating from an acute phase of heart disease may have also had a stroke which could require physical and/or occupational therapies).

Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered experimental/investigational and therefore, non-covered. Scientific evidence does not support the need for repeat cardiac rehabilitation in the absence of cardiac events.

Educational services (e.g., lectures, counseling) that may be provided as part of a cardiac rehabilitation exercise program are not eligible for separate reimbursement.

Phase III cardiac rehabilitation programs, or self-directed, self-controlled or monitored exercise programs are considered not medically necessary.

Phase IV cardiac rehabilitation programs or maintenance therapy that may be safely carried out without medical supervision are considered not medically necessary.

Cardiac rehabilitation when used in a preventive or prophylactic way, such as for angina, hypertension, or diabetes is considered not medically necessary. 

93797

93798

G0422

G0423

 

 

 

 




Home Based Cardiac Rehabilitation

 Home based Cardiac Rehabilitation Programs, with on-line supervision, for Phase II Outpatient  individuals may be considered medically necessary.

Home based Cardiac Rehabilitation Programs not meeting the criteria as indicated in this policy is considered not medically necessary. 

93797

93798

G0422

G0423

 

 

 




Risk stratification based on the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).

Cardiac rehabilitation services are contraindicated for individuals with ANY of the following conditions:

  • A recent significant change in the resting ECG suggesting significant ischemia, recent MI (within two (2) days), or other acute cardiac event;
  • Severe residual angina; or
  • Uncompensated heart failure; or
  • Uncontrolled arrhythmias; or
  • Symptomatic severe aortic stenosis; or
  • Severe ischemia, LV dysfunction, or arrhythmia during exercise testing; or
  • Poorly controlled hypertension; or
  • Acute pulmonary embolism or pulmonary infarction; or
  • Acute myocarditis or pericarditis; or
  • Suspected or known dissecting aneurysm; or
  • Acute systemic infection, accompanied by fever, body aches, or swollen lymph glands; or
  • Hypertensive or any hypotensive systolic blood pressure response to exercise.

Relative contraindications to exercise include ANY if the following:

  • Left main coronary stenosis; or
  • Moderate stenotic valvular heart disease; or
  • Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia); or
  • Severe arterial hypertension (i.e., systolic BP greater than 200mm Hg and/or diastolic BP of greater than 110 mm Hg) at rest; or
  • Tachydysrhythmia or brady-dysrhythmia; or
  • Hypertrophic cardiomyopathy and other forms of outflow tract obstruction; or
  • Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise; or
  • High-degree atrioventricular block; or
  • Ventricular aneurysm; or
  • Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or myxedema); or
  • Chronic infectious disease (e.g., mononucleosis, hepatitis, AIDS); or
  • Mental or physical impairment leading to inability to exercise adequately.

The participant’s risk for another coronary event determines the status of the individual as a high, moderate, or low-risk. Use of early (pre-discharge) exercise testing, with or without radionuclide studies, provides the ability to determine the probability of a proximate ischemic event. Risk stratification testing benefits all participants regardless of their level of risk.

Initially, a comprehensive evaluation may be performed to evaluate the participant and determine an appropriate exercise program.

In addition to typical program duration, an endpoint for cardiac rehabilitation services may also be determined using the participant's work capacity as measured by metabolic equivalents of task (MET). A MET is the measurement of the work required from the cardiovascular and pulmonary systems by a given activity. One MET equals approximately 3.5 ml of oxygen consumption per kilogram of body weight per minute. 

Depending on variables such as age, sex, cardiac history, the existence of other complicating medical conditions, etc., work capacity usually levels out at a maximal level of five (5) to eight (8) METs for most cardiac rehabilitation participants. Reasonable endpoint criteria for medically supervised cardiac rehabilitation programs can include the ability of the participant to exercise at a level of eight (8) or more.

METs without cardiac symptoms and the acquisition of the skills necessary for the self-monitoring of an unsupervised exercise program.

Since many participants with cardiac disease will not be capable of achieving this level of work capacity, the absence of improvement in capacity after three (3) serial exercise tests can be used as an alternative endpoint indicator.

Once a participant’s maximal work capacity has leveled out, ongoing exercise is considered maintenance. Additional cardiac rehabilitation services are eligible based on the clinical criteria defined in this policy when the individual has a repeat occurrence of the covered conditions, e.g., another cardiovascular surgery, a new MI, etc.


Professional Statements and Societal Positions Guidelines

The American College of Cardiology Foundation and the American Heart Association, 2013

In 2013, the American College of Cardiology Foundation and the American Heart Association published updated guidelines on the management of heart failure.  These guidelines include the following Class IIA recommendation related to cardiac rehabilitation (Level of Evidence: B): Cardiac rehabilitation can be useful in clinically stable individuals with heart failure to improve functional capacity, exercise duration, HRQOL (health-related quality of life), and mortality.

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, 2012

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.  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 individuals at first diagnosis of stable ischemic heart disease.


Covered Diagnosis Codes For procedure codes 93797, 93798, G0422, and G0423

A18.84

I21.01

I21.02

I20.1

I20.2

I20.8

I20.81

I20.89

I20.9

I21.09

I21.11

I21.19

I21.21

I21.29

I21.3

I21.4

I21.9

I21.A1

I21.A9

I22.0

I22.1

I22.2

I22.8

I22.9

I24.89

I25.10

I25.110

I25.111

I25.112

I25.118

I25.119

I25.2

I25.3

I25.700

I25.701

I25.702

I25.708

I25.709

I25.710

I25.711

I25.712

I25.718

I25.719

I25.720

I25.721

I25.722

I25.728

I25.729

I25.730

I25.731

I25.732

I25.738

I25.739

I25.750

I25.751

I25.752

I25.758

I25.759

I25.760

I25.761

I25.762

I25.768

I25.769

I25.790

I25.791

I25.792

I25.798

I25.799

I25.810

I25.811

I25.812

I42.0

I42.1

I42.2

I42.3

I42.4

I42.5

I42.6

I42.7

I42.8

I42.9

I43

I46.2

I46.8

I46.9

I50.1

I50.20

I50.21

I50.22

I50.23

I50.30

I50.31

I50.32

I50.33

I50.40

I50.41

I50.42

I50.43

I50.9

Z48.21

Z48.280

Z94.1

Z94.3

Z95.1

Z95.2

Z95.3

Z95.4

Z95.5

Z98.61

Z98.890

 

 



Place of Service: Outpatient

Cardiac Rehabilitation Programs, Phase II Outpatient 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.