Clinical UM Guideline


Subject:  Cardiac Rehabilitation (Outpatient)
Guideline #:  CG-REHAB-02Current Effective Date:  01/14/2014
Status:RevisedLast Review Date:  11/14/2013

Description

Cardiac rehabilitation is broken down into 4 phases. This document addresses cardiac rehabilitation services that are provided on an outpatient basis during the immediate post-discharge period and are considered Phase II Cardiac Rehab Programs (see Discussion/General Information section for further information related to the phases of Cardiac Rehabilitation Programs).

Clinical Indications

Medically Necessary:

Phase II cardiac rehabilitation is considered medically necessary when individually prescribed by a physician and the following criteria are met:

  1. Cardiac rehabilitation is initiated within 12 months of ANY of the following:
    • Acute myocardial infarction (MI); or
    • Coronary artery bypass grafting (CABG); or
    • Heart transplantation; or
    • Percutaneous coronary intervention (i.e., atherectomy, angioplasty, stenting); or
    • Survivor of sudden cardiac death; or
    • Survivor of sustained ventricular tachycardia or fibrillation; or
    • Valve replacement or repair; or
    • Class III or IV congestive heart failure (CHF) that has failed to respond to pharmacotherapy and is interfering with the ability to perform age-related activities of daily living; or
    • Coronary artery disease (CAD) with chronic stable angina pectoris that has failed to respond to pharmacotherapy and is interfering with the ability to perform age-related activities of daily living;
      AND
  2. 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);
    AND
  3. A formal exercise stress test has been completed following the qualifying cardiac event and prior to initiation of the rehab program or, for individuals at low risk based on current symptoms, clinical features and exercise history, during the first rehabilitation session.

Not Medically Necessary: 

The following are considered not medically necessary:

  1. Phase III cardiac rehabilitation programs, or self-directed, self-controlled or monitored exercise programs;
  2. Phase IV cardiac rehabilitation programs or maintenance therapy that may be safely carried out without medical supervision;
  3. Cardiac rehabilitation when used in a preventive or prophylactic way, such as for angina, hypertension, or diabetes.
Place of Service and Frequency/Duration

Place of Service: Ambulatory, Outpatient Facility

Frequency/Duration:
The frequency and duration of treatment is determined by the following:

High Risk:
Individuals in the high-risk category may have ANY of the following:

Cardiac Rehabilitation Programs for high-risk individuals may include the following:

Note: If no clinically significant arrhythmia is documented during the first three weeks of the program, the remaining portion may be completed without telemetry monitoring.

Intermediate Risk:
Individuals in the intermediate risk category may have ANY of the following:

Cardiac Rehabilitation Programs for intermediate risk individuals may include the following:

Low Risk:
Individuals in the low risk category may have ANY of the following:

Cardiac Rehabilitation Programs for low risk individuals may include the following:

Additional cardiac rehabilitation services are considered medically necessary based on the above listed criteria in the event the individual has ANY of the following:

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
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)
  
HCPCS 
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
S9472Cardiac rehabilitation program, non-physician provider, per diem
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
  
Discussion/General Information

Cardiac rehabilitation is a program of multidisciplinary interventions, designed to assist clinically suitable individuals to attain and maintain their optimal level of functioning. Over the past two decades, risk factor modification programs for individuals with cardiac conditions, commonly referred to as cardiac rehabilitation, have evolved into a comprehensive management strategy. The American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) define cardiac rehabilitation programs as, "Coordinated, multifaceted interventions designed to optimize a cardiac patient's physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality" (Leon, 2005). Interventions include, "Baseline patient assessments, nutritional counseling, aggressive risk factor management, (i.e., lipids, hypertension, weight, diabetes, and smoking), psychosocial and vocational counseling, and physical activity counseling and exercise training, in addition to the appropriate use of cardioprotective drugs" (Leon, 2005).

According to a 2007 scientific statement from the AHA and the AACVPR (Balady, 2007), which addresses the core components of cardiac rehabilitation/secondary prevention programs, the following is noted:

Symptom-limited exercise testing is strongly recommended prior to participation in an exercise-based CR program. The evaluation may be repeated as changes in clinical condition warrant. Test parameters should include assessment of heart rate and rhythm, signs, symptoms, ST-segment changes, hemodynamics, perceived exertion, and exercise capacity. On the basis of patient assessment and the exercise test if performed, it is recommended to risk stratify the patient to determine the level of supervision and monitoring required during exercise training.

A Cochrane review by Heran (2011) concluded that "Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium to longer term studies) and hospital admissions (in shorter term studies) but not total MI or revascularization (CABG or PTCA)." Goel and colleagues (2011) conducted a retrospective review which looked at 2395 individuals over a 14 year period that underwent percutaneous coronary intervention. Of the 2395 individuals who underwent percutaneous coronary intervention, 964 of them enrolled in cardiac rehabilitation following the intervention. Mean follow-up was 6.3 years. During that time there were 503 deaths, of which 199 were due to cardiovascular disease. Revascularization was required in 755 individuals and 394 individuals had subsequent myocardial infarction. The authors reported a 45% to 47% decrease in mortality of those individuals who participated in cardiac rehabilitation after percutaneous intervention compared with those individuals who did not participate in cardiac rehabilitation.

Exercise training is the principal component of cardiac rehabilitation, since it results in increased peak exercise capacity, which is usually expressed in METs (metabolic equivalents). This is the total oxygen requirement of the body, with 1 MET equal to 3.5 mL of oxygen consumed per kilogram of body weight per minute. Exercise training improves MET capacity by 10% to 50%, resulting in improved oxygen delivery and extraction by exercising skeletal muscles, thereby decreasing the cardiovascular requirements of exercise and increasing the amount of work that can be done before ischemia occurs. Although dynamic aerobic exercise is necessary to improve cardiovascular endurance, resistance exercise is becoming a useful adjunctive component of the exercise regimen as well. Resistance training should be included in the exercise program to minimize loss of muscle mass.

CR programs are generally divided into four phases: phase I, inpatient or recovery phase; phase II, outpatient or intermediate phase; phase III, community-based or home long-term phase; phase IV, maintenance (Thompson, 2007).

Phases of Cardiac Rehabilitation

Phase

Type of Program

Duration

Description

I

InpatientDays
  • Inpatient or recovery phase
  • Begins as soon as the individual is medically stable following a cardiac event (e.g., myocardial infarction, bypass surgery) and continues while the individual remains in the hospital
  • Consists of 1) early assumption of upright posture; 2) progressive exercise and self-care based on individual tolerance; 3) education; and 4) risk factor identification and initial attempts at modification.

II

Outpatient, immediately after hospitalization2 – 12 weeks
  • Outpatient or intermediate phase
  • Initiated within a few weeks after hospital discharge
  • Consists of 1) supervised exercise training to maximize functional capacity, teach safe exercise practices, and identify individuals at risk for complications; 2) risk factor modification; and 3) education about medications, signs and symptoms of heart disease and its progression, dietary modifications and activity guidelines.

III

Late recovery periodMinimum of 6 months beyond phase II
  • Community-based or home long-term phase
  • Consists of a lifelong program committed to encourage exercise and a healthful lifestyle to minimize recurrence of cardiac problems.
  • Such programs are usually undertaken at home or in a fitness center.

IV

MaintenanceIndefinite
  • Consists of efforts to modify risk factors and a routine program of physical activity that individuals should continue indefinitely.
  • For some programs, phase IV rehabilitation is combined with phase III.  All cardiac rehabilitation programs, however, recommend some form of indefinite maintenance for their participants. 
Definitions

Duke Treadmill Score (DTS): A quantitative means of expressing cardiac risk derived entirely from the exercise ECG. It incorporates ST segment deviation (depression or elevation), treadmill time (METS) and exercise-induced angina. The angina index has a value of 0 if there is no angina during exercise, 1 if the individual had non-limiting angina and 2 if angina was the reason the individual stopped exercising. The typically observed range for the DTS is highest risk of –25 to lowest risk of +15.

References

Peer Reviewed Publications:

  1. Dafoe W, Huston P. Current trends in cardiac rehabilitation. Can Med Assoc J. 1997; 156(4):527-532.
  2. Deedwania PC, Amsterdam EA, Vagelos RH. Evidence-based, cost-effective risk stratification and management after myocardial infarction. Arch Intern Med. 1997; 157(3):273-280.
  3. Goel K, Lennon RJ, Tilbury RT, et al. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation. 2011; 123(21):2344-2352.
  4. Keteyian SJ, Levine AB, et al. Exercise training in patients with heart failure: A randomized, controlled trial. Ann Intern Med. 1996; 124(12):1051-1057.
  5. Kobashigawa JA, Leaf DA, Lee N, et al. A controlled trial of exercise rehabilitation after heart transplant. N Engl J Med. 1999; 340(4):272-277.
  6. Roitman JL, LaFontaine, T, Drimmer AM. A new model for risk stratification & delivery of cardiovascular rehabilitation services in the long-term clinical management of patients with coronary artery disease. J Cardiopulmonary Rehabil. 1998; 18(2):113-123.
  7. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004; 116(10):682-692
  8. Wilson JR, Groves J, Rayos G. Congestive heart failure/heart transplantation/pulmonary circulation: Circulatory status and response

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007; 115(20):2675-2682.
  2. Francis GS, Greenberg BH, Hsu DT, et al. 2010 Clinical Competence Statement on Management of Patients With Advanced Heart Failure and Cardiac Transplant A Report of the ACCF/AHA/ACP Task Force on Clinical Competence and Training. Circulation. 2010; 122(6):644-672.
  3. Heran BS, Chen JMH, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011; (7):CD001800.
  4. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for coronary artery bypass graft surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011; 58(24):e123-210. Available at: http://content.onlinejacc.org/article.aspx?articleid=1147818. Accessed on September 23, 2013.
  5. Institute for Clinical Systems Improvement (ICSI). Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS). 2012. Available at: http://www.icsi.org. Accessed on September 23, 2013.
  6. King ML, Williams MA, Fletcher GF, et al. Medical director responsibilities for outpatient cardiac rehabilitation/secondary prevention programs: A scientific statement from the American Heart Association/American Association for Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005; 112(21):3354-3360.
  7. Leon AS, Franklin BA, Costa F et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005; 111(3):369-376.
  8. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.J Am Coll Cardiol. 2011; 58(24):e44-122. Available at: http://content.onlinejacc.org/article.aspx?articleid=1147816. Accessed on September 23, 2013.
  9. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women – 2011 update. A guideline for the American Heart Association. J Am Coll Cardiol, 2011; 57(12):1404-1423.
  10. Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: A report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation). J Cardiopulm Rehabil Prev. 2010; 30(5):279-288. Available at: http://journals.lww.com/jcrjournal/Fulltext/2010/09000/AACVPR_ACCF_AHA_2010_Update___Performance_Measures.1.aspx. Accessed on September 23, 2013.
  11. Thompson PD. Chapter 46: Comprehensive rehabilitation of patients with cardiovascular disease. In: Zipes DP, Libby P, Bonow RO, Braunwald E, editors. Braunwald's heart disease. A textbook of cardiovascular disease. 8th ed. Philadelphia: Saunders. 2007.
  12. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. Circulation. 2013 Jun 5. Available at: http://circ.ahajournals.org/content/early/2013/06/03/CIR.0b013e31829e8776.full.pdf. Accessed on September 27, 2013.
Web Sites for Additional Information
  1. American Heart Association (AHA). What is cardiac rehabilitation? Available at: http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp. Accessed on September 23, 2013.
Index

Cardiac Rehabilitation
Phase II Cardiac Rehabilitation

History
StatusDateAction
Revised11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Clarification to the Medically Necessary statement. Updated References.
Reviewed11/08/2012MPTAC review. Updated Discussion/General Information and References.  Updated Coding section with 01/01/2013 CPT descriptor changes; removed revenue code 0943.
Reviewed11/17/2011MPTAC review. Updated Coding, Description, Discussion/General Information, References and Web Sites for Additional Information.
Reviewed11/18/2010MPTAC review. Updated Discussion/General Information and References.
Reviewed11/19/2009MPTAC review. No change to criteria. References were updated. Updated Coding section with 01/01/2010 HCPCS changes.
Revised11/20/2008MPTAC review. A criterion was revised to clarify the timing and need for pre-rehab program stress testing or for testing during the first CR session for low risk patients. The requirement under 'Frequency/Duration' of services for pre-rehab testing within three weeks of initiating the CR Program was removed. Also, the time for initiation of a Cardiac Rehab Program following the qualifying cardiac event was changed from six months to within twelve months. Annual review was also performed. Discussion section and References were also updated.
Reviewed05/15/2008MPTAC review. No change to criteria. References were updated.
Reviewed05/17/2007MPTAC review. No change to guideline criteria. References were updated.
Reviewed06/08/2006MPTAC review. No change to guideline criteria. The Discussion section and References updated to include the 2005 AHA/AACVPR guideline and the 2005 AHRQ Technology Assessment. 
 11/17/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised09/22/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger OrganizationsLast Review DateDocument NumberTitle

Anthem Midwest

 

04/08/2005RA-011Cardiac Rehabilitation (Midwest Medical Review & Utilization Management Criteria)
Anthem West Region10/01/2004UMR.001Cardiac Rehabilitation, Outpatient
Anthem SoutheastN/AMemo 1111Cardiac Rehabilitation
Anthem CT  Cardiac Rehabilitation Benefit Detail
Anthem ME  Cardiac Rehabilitation Benefit Detail
WellPoint Health Networks, Inc.12/02/20042.04.01Cardiac Rehabilitation
 12/02/2004Clinical GuidelineCardiac Rehabilitation