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).

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 has no absolute contraindications to cardiac rehabilitation as indicated by absence of the following,:
   • (e.g., unstable angina pectoris, overt cardiac failure, dangerous arrhythmias, dissecting aneurysm, myocarditis or pericarditis (acute), severe obstruction of the left ventricular outflow tract, severe hypertension, exertional hypotension or syncope, uncontrolled diabetes mellitus, severe orthopedic limitations, 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: Ambulatory, Outpatient Facility

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

• The cardiac risk level; and
• The degree of exercise limitation as demonstrated by a treadmill electrocardiogram (ECG) stress test.

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

• Exercise test limited to less than or equal to 5 metabolic equivalents (METS). (MET = a multiple of the resting energy expenditure, and is used as a means of estimating cardiac functional capacity. [1 MET = 3.5ml O2/kg body wt/min]); or
• Marked exercise-induced ischemia, as indicated by either anginal pain or 2 mm or more ST segment depression by ECG; or
• Severely depressed left ventricular function (ejection fraction less than 30%); or
• Resting complex ventricular arrhythmias; or
• Ventricular arrhythmias appearing or increasing with exercise or occurring in the recovery phase of stress testing; or
• Decrease in systolic blood pressure of greater than 15 mm Hg with exercise; or
• Recent myocardial infarction (less than 6 months) which was complicated by serious ventricular arrhythmias, cardiogenic shock, or congestive heart failure (CHF); or
• Survivor of sudden cardiac arrest.

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

• 36 sessions (e.g., 3x/wk x 12 wks) of supervised exercise with continuous telemetry monitoring; and
• Educational program for risk factor/stress reduction; and
• Creation of an individual outpatient exercise program that can be self-monitored and maintained.

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:

• Exercise test limited to 6-9 METS; or
• Ischemic ECG response to exercise of less than 2 mm of ST segment depression; or
• Uncomplicated myocardial infarction, coronary artery bypass surgery, or angioplasty and has a post-cardiac event maximal functional capacity of 8 METS or less on ECG exercise test.

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

• Provide exercise training for 24 sessions or less of exercise training without continuous ECG monitoring (Note: Some individuals may require less than 3x/wk x 8 wks); and
• Be geared towards defining an ongoing exercise program that is self-administered.

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

• Exercise test limited to greater than 9 METS; or
• Asymptomatic at rest.

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

• 6 one-hour sessions involving risk factor reduction education; and
• Supervised exercise to show safety and define a home program (e.g., 3x/week x 2wks or 2x/week x 3wks).

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

• Another documented myocardial infarction or extension of initial infarction; or
• Another cardiovascular surgery or angioplasty; or
• New evidence of ischemia on an exercise test, including thallium scan; or
• New clinically significant coronary lesions documented by cardiac catheterization.

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.

Cardiac rehabilitation is a program of multidisciplinary interventions, designed to assist clinically suitable individuals to attain and maintain their optimal level of functioning, as defined by the United States Public Health Service (Wenger, 1995):

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.

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 recent 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

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.

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. 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.
4. 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.
5. 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.
6. 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
7. Wilson JR, Groves J, Rayos G. Congestive heart failure/heart transplantation/pulmonary circulation: Circulatory status and response to cardiac rehabilitation in patients with heart failure. Circulation 1996; 94(7):1567-1572.

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. Brown A, Noorani H, Taylor R, et al. A clinical and economic review of exercise-based cardiac rehabilitation programs for coronary artery disease. Technology Overview No. 11. Ottawa, ON: Canadian Coordinating Office for Health Technology Assessment (CCOHTA). August 2003.
3. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004; 110(9):1168-1176.
4. Fraker TD Jr, Fihn SD; 2002 Chronic Stable Angina Writing Committee; American College of Cardiology; American Heart Association. 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 guidelines for the management of patients with chronic stable angina. J Am Coll Cardiol. 2007; 50(23):2264-2274.
5. 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.
6. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). 2002. Circulation. 2002; 106(14):1883-1892.
7. 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.
8. Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendations for stroke survivors: An American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation and Prevention. The Council on Cardiovascular Nursing, the Council on Nutrition, Physical Activity, and Metabolism, and the Stroke Council. Circulation. 2004; 109(16):2031-2041.
9. Heran BS, Chen JMH, Ebrahim S, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011; (7):CD001800.
10. Institute for Clinical Systems Improvement (ICSI). Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS). 2010. Available at: http://www.icsi.org. Accessed on August 9, 2011.
11. 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.
12. King SB 3rd, Smith SC Jr, Hirshfeld JW Jr, et al. 2007 Focused update of the ACC/AHA/SCAI 2005 Guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: 2007 Writing Group to Review New Evidence and Update the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention, Writing on Behalf of the 2005 Writing Committee. Circulation. 2008; 117(2):261-295.
13. 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.
14. 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.
15. Skinner JS, Cooper A, Feder GS; Guideline Development Group. Secondary prevention for patients following a myocardial infarction: summary of NICE guidance. Heart. 2007; 93(7):862-864.
16. 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 August 9, 2011.
17. 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.
18. Wenger, NK, Froelicher ES, Smith L, et al. Cardiac rehabilitation Clinical Practice Guideline No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute. AHCPR Publication No. 96-0672. October 1995.

1. American Heart Association (AHA). What is cardiac rehabilitation? Updated September 30, 2011.  Available at: http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp. Accessed on August 12, 2011.

Cardiac Rehabilitation
Phase II Cardiac Rehabilitation